A pregnant patient’s biophysical profile score is 8. The patient asks the nurse to explain the results. What is the nurse’s most appropriate response?
The test results are within normal limits.”
Which analysis of maternal serum is the best predictor of chromosomal abnormalities in the fetus?
Multiple-marker screening
The clinic nurse is obtaining a health history on a newly pregnant patient. Which is an indication for fetal diagnostic procedures if present in the health history?
Maternal diabetes
What point in the pregnancy is the most accurate time to determine gestational age through ultrasound?
First trimester
The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine whether the fetus has which condition?
A neural tube defect
When is the earliest interval that chorionic villus sampling (CVS) can be performed during pregnancy?
10 weeks
Which aspect of fetal diagnostic testing is most important to expectant parents?
Safety of the fetus
The nurse’s role in diagnostic testing is to provide which of the following?
Information about the tests
Which factors should be considered a contraindication for transcervical chorionic villus sampling?
Positive for group B Streptococcus
What is the purpose of amniocentesis for a patient hospitalized at 34 weeks of gestation with pregnancy-induced hypertension?
Determine fetal lung maturity.
What does optimal nursing care after an amniocentesis include?
Monitoring uterine activity
What is the term for a nonstress test in which there are two or more fetal heart rate accelerations of 15 or more beats per minute (BPM) with fetal movement in a 20-minute period?
Reactive
What is the purpose of initiating contractions in a contraction stress test (CST)?
Apply a stressful stimulus to the fetus.
A biophysical profile is performed on a pregnant patient. The following assessments are noted: nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs), limited gross movements, opening and closing of hang indicating the presence of fetal tone, and adequate amniotic fluid index (AFI) meeting criteria. Which answer would be the correct interpretation of this test result?
A score of 8 would indicate normal results.
In preparing a pregnant patient for a nonstress test (NST), which of the following should be included in the plan of care?
Position the patient for comfort, adjusting the tocotransducer belt to locate fetal heart rate.
The results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test result?
Contact the health care provider to discuss birth options for the patient.
A pregnant patient has received the results of her triple-screen testing and it is positive. She provides you with a copy of the test results that she obtained from the lab. What would the nurse anticipate as being implemented in the patient’s plan of care?
Refer to the physician for additional testing.
A pregnant woman is scheduled to undergo chorionic villus sampling (CVS) based on genetic family history. Which medication does the nurse anticipate will be administered?
RhoGAM if the patient is Rh-negative
For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
A 24-year-old gravida 1, para 0, who has diabetes
Which complication could occur as a result of percutaneous umbilical blood sampling (PUBS)?
Fetal bradycardia
A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patient’s health care provider. When is the best time for the nurse to schedule the patient’s ultrasound?
Immediately
The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks’ gestation. The nurse determines that the patient understands the teaching when she states that will be collected for the initial screening process?
Blood
A patient at 36 weeks gestation is undergoing a nonstress (NST) test. The nurse observes the fetal heart rate baseline at 135 beats per minute (bpm) and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse record these findings?
NST reactive, reassuring
Which clinical conditions are associated with increased levels of alpha fetoprotein (AFP)? (Select all that apply.)
Twin gestation
Incorrect gestational age assessment of a normal fetus—estimation is earlier in the
pregnancy
Threatened abortion
Transvaginal ultrasonography is often performed during the first trimester. A 6-week-gestation patient expresses concerns over the necessity for this test. The nurse should explain that this diagnostic test may be necessary to determine which of the following? (Select all that apply.)
Multifetal gestation
Bicornuate uterus
Presence and location of pregnancy
Presence of ovarian cysts
A woman who is 36 weeks pregnant asks the nurse to explain the vibroacoustic stimulator (VAS) test. Which should the nurse include in the response? (Select all that apply.)
The test uses sound to elicit fetal movements.
The test may confirm nonreactive nonstress test results.
Vibroacoustic stimulation can be repeated at 1-minute intervals up to three times.
The nurse is instructing a patient on how to perform kick counts. Which information should the nurse include in the teaching session? (Select all that apply.)
Use a clock or timer when performing kick counts.
Protocols can provide a structured timetable for concentrating on fetal movements.
You should lie on your side, place your hands on the largest part of the abdomen,and concentrate on the number of movements felt.
The nurse is preparing a patient for a nonstress test (NST). Which interventions should the nurse plan to implement? (Select all that apply.)
Have the patient sit in a recliner with the head elevated 45 degrees.
Apply electronic monitoring equipment to the patient’s abdomen.
Instruct the patient to press an event marker every time she feels fetal movement.
Critical care of the obstetric patient in the Intensive Care Unit is complicated by
ICU nurses not having Fetal Heart Rate Monitoring experience
Betamethasone for fetal lung maturity is recommended between
weeks gestation.
23 and 36 6/7
Magnesium sulfate for fetal neuroprotection is an option for patients at high risk for delivery between weeks gestation, if a contraindication does not exist.
23 and 36 6/7
An obstetric patient has presented to the clinic with a heart rate of 140, blood pressure of 90/56, and labored respiratory rate of 20. The patient is pale and reports frequent vomiting and has not been able to keep anything down for over 24 hours. The nurse recognizes that the patient is presenting signs of
Hypovolemia
Which of the following is NOT a cause of disseminated intravascular coagulation (DIC)?
Trauma to the uterine wall
The nurse is aware that which diagnosis places the maternal patient at higher risk for sepsis?
Urinary Tract Infection
The nurse is preparing to administer antibiotics to the maternal patient with suspected sepsis. The nurse is aware that the antibiotic dose should be given when?
Within an hour of recognition of sepsis risk
The nurse reviewing is reviewing the lab results for a pregnant patient who presented with signs and symptoms of sepsis. The nurse notes that the lactate level is 3 mmol/L. What can the nurse conclude from this finding?
inconclusive based on the lactate level alone.
is a rare event during delivery where the maternal patent experiences a profound inflammatory response to amniotic fluid entering the circulatory system.
AFE
The clinic nurse is getting the maternal patient ready to see the provider for her urgent care visit related to increased fatigue and vomiting. The nurse notices that the patient has a fruity odor to her breath. Which action should the nurse take next?
Obtain a blood glucose measurement
The nurse answers the call light for a patient on the L&D floor. The patient, in active labor, states “something is wrong, I feel really anxious” and then loses consciousness. The nurse assesses and finds the patient has no pulse. Which action should the nurse take next?
Initiate basic life support
is the abnormal accumulation of blood outside of the vascular space in the lungs?
Pulmonary Edema
A nursing student is helping the mother-baby nurse with morning vital signs. A baby born 10 hours ago via cesarean birth is found to have moist lung sounds. Which is the best interpretation of this information?
The lungs of a baby delivered by cesarean birth may sound moist for 24 hours after birth.
Which of the following organs are nonfunctional during fetal life?
Lungs and liver
Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands?
Conduction
How can nurses prevent evaporative heat loss in the newborn?
Drying the baby after birth and wrapping the baby in a dry blanket
The nurse is explaining how a newly delivered baby initiates respirations. Which statement explains this process most accurately?
Chemical, thermal, and mechanical factors
During fetal circulation the pressure is greatest in the
right atrium.
The infant’s heat loss immediately at birth is predominantly from
evaporation.
The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which statement best describes the manifestations of hypothermia in the newborn?
Newborns have increased glucose demands
Which infant has the lowest risk of developing high levels of bilirubin?
The infant who is breastfed during the first hour of life
The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which statement is important to understand regarding the properties of vitamin K?
It is not initially synthesized because of a sterile bowel at birth.
A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is
passed in the first 24 hours of life.
Which of the following is the most likely cause of regurgitation when a newborn is fed?
A relaxed cardiac sphincter
The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as
conjugation of bilirubin.
A newborn is admitted to the special care nursery with hypothermia. Which complication should the nurse monitor for closely?
Metabolic acidosis
Which action by the nurse can result in hyperthermia in the newborn
Placing the newborn in the radiant warmer without attaching the skin probe
A multiparous patient arrives to the labor unit and urgently states, “The baby is coming RIGHT NOW!” The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action?
Place the baby on the patient’s abdomen after the cord is cut.
The nurse is planning to conduct the initial assessment of a full-term newborn. Included in the plan is providing a neutral thermal environment. To accomplish this plan, what is the desired environmental temperature to conduct the assessment?
32 to 33 (89.6 to 92.3)
An infant at 39 weeks’ gestation was just delivered; included in the protocol for a term infant is an initial blood glucose assessment. The nurse obtains the blood sample and the reading is 58 mg/dL. What is the priority nursing action based upon this reading?
Document the finding in the newborn’s chart.
During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels?
Dilation of pulmonary vessels
Which infant is at greater risk to develop cold stress?
36-week infant with an Apgar score of 7 to 9.
A reported hematocrit level for a newborn delivered by vaginal birth is 75%. Based on this lab value, which complication is the newborn least likely to develop?
Infection
In the newborn nursery, you are reviewing the maternal medication list to ascertain if there is any significant risk to the newborn. Which medications would pose a potential risk to the newborn in terms of clotting ability? (Select all that apply.)
Carbamazepine
Phenytoin (Dilantin)
Phenobarbital
INH (Isoniazid)
The nurse is teaching the postpartum patient about newborn transitional stools. Which should the nurse include in the teaching session with regard to transitional stools? (Select all that apply.)
They are a greenish brown color.
They are of a looser consistency.
Which newborn is at higher risk for developing hypoglycemia? (Select all that apply
Post-term newborn
Small-for-gestational-age newborn
Large-for-gestational-age newborn
The hips of a newborn are examined for developmental dysplasia. Which clinical finding indicates an incomplete development of the acetabulum?
Thigh and gluteal creases are asymmetric.
Which newborn reflex is elicited by stroking the lateral sole of the infant’s foot from the heel to the ball of the foot?
Babinski
Infants who develop cephalohematoma are at an increased risk for
jaundice.
Which statement best explains why a newborn with a congenital defect of the penis should not be circumcised?
The foreskin might be needed for future repairs.
A maculopapular rash with a red base and a small white papule in the center is commonly known as
erythema toxicum.
A newborn that is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight?
Greater than the 90th
A new patient asks, “Why are you doing a gestational age assessment on my baby?” The nurse’s best response is
It helps us identify infants who are at risk for any problems.”
Which nursing action is designed to avoid unnecessary heat loss in the newborn?
Place a blanket over the scale before weighing the infant.
The nurse is performing a gestational age assessment on a newborn. Which characteristic indicates the greatest gestational maturity?
There is some peeling and cracking of the skin.
A new mother states, “My baby is so thin and wrinkled. It looks like he has too much skin.” Which is the most therapeutic response by the nurse in response to the patient’s statement?
You sound worried about how he looks, is that right?”
Which assessment finding of a newborn requires prompt action by the nurse?
Pause in breathing lasting 20 seconds
The nurse is receiving shift report on her mother-baby couplet assignment. Which infant should the nurse evaluate first?
40-weeks’ gestation female newborn with reported poor feed at last attempt
Inspection of a newborn’s head following birth reveals a hard ridged area and significant molding. The anterior and posterior fontanels show no sign of depression. Delivery history indicates that the mother was pushing for over 3 hours and had epidural anesthesia. A vacuum extraction was necessary. Based on this information the nurse would
contact the pediatric provider.
The nurse is performing the initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system?
Respiratory
The mother-baby nurse is providing care to a patient and her newborn 2 hours after delivery. On review of the newborn’s chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mother’s chart?
A longer than usual labor
The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding?
Depress the tip of the nose.
An infant at term was born at 0105 hours. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score?
0200 to 0600
The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the following figures depicts this birthmark?
C
The nurse is conducting a body system assessment of the newborn. Which are abnormal findings that the nurse should report? (Select all that apply.)
Low-set ears
Yellow sclera
Absence of the grasp reflex
To differentiate between caput succedaneum and cephalohematoma in a newborn, the nurse would consider the following clinical information. (Select all that apply.)
A cephalohematoma can develop several hours or days after the birth event,whereas caput succedaneum is noted shortly before or immediately after the birth event.
Edema that crosses suture lines is observed with caput succedaneum.
With a cephalohematoma, bleeding occurs between the bone and skull.
Which clinical findings are early signs of hypoglycemia in the newborn? (Select all that apply.)
Jitteriness
Poor feeding
Respiratory difficulty
The nurse is performing a gestational age assessment on a newborn. Which characteristics indicate a preterm newborn? (Select all that apply.)
Translucent skin
Extended limp arms and legs
Large clitoris and labia minora in the female newborn
A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital 5 days after her son was circumcised. She is very concerned. Which response by the nurse is most appropriate?
The yellow crust should not be removed.
Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is optimal for the newborn?
Vastus lateralis muscle
Which information should the nurse teach to new parents regarding the use of a bulb syringe?
Insert the syringe into the sides of the mouth.
In providing and teaching cord care, which guidance is most appropriate?
Keeping the cord dry will decrease bacterial growth
Which of the following guidelines should the nurse implement to prevent the abduction of a newborn from the hospital?
Questioning anyone who is seen walking in the hallways carrying an infant
A nursing student has been caring for a patient and newborn all morning. After taking the newborn to the nursery for hearing screening, the student is returning the infant to his mother. Which procedure is correct for identifying the newborn?
Have the mother read her printed band number and verify that it matches the infant’s number.
The nurse is explaining the procedure of newborn screening to parents prior to discharge. Which statement by the parents indicates a need for further teaching?
We wish the tests would screen for congenital hypothyroidism, it runs in our family.
Which newborn assessment finding requires the nurse to take immediate action?
Glucose level of 40 mg/dL
The nurse is evaluating a newborn’s circumcision 30 minutes after the procedure. The nurse notes excessive bleeding coming from the circumcised area. Which priority intervention should the nurse implement at this time?
Apply pressure to the site.
In which position should the parents be instructed to place their newborn for sleep?
On the back
A 38 weeks’ gestation fetus is delivered via cesarean birth and transported to the newborn nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an initial assessment in the newborn nursery. Which is the priority nursing diagnosis?
Risk for ineffective airway clearance due to mode of delivery and use of anesthetics
An infant’s temperature is recorded at 36°C (96.8°F) during the morning assessment. Which action should the nurse take?
Make sure that the infant is wrapped securely with a blanket and recheck temperature in 15 minutes.
When an infant’s temperature drops from (37 to 36.3°C) 98.7 to 97.4°F, the nurse should
determine the time and amount of last feeding
Administration of medications after birth is the topic of discussion during a prenatal education class. Which statement indicates to the nurse that the pregnant patient understands the primary indication for the administration of vitamin K?
“Vitamin K prevents the possibility of bleeding problems in my baby.”
An hour after birth, the nurse assesses a newborn’s temperature and notes that it is 36.2°C (97.2°F). The next activity planned for the newborn is the bath, and the new mother and father are invited to participate in the procedure. What is the nurse’s next action?
Delay the bath until the newborn’s temperature is above 36.7°C (98°F).
Which intervention will be most helpful to parents in identifying problems with an infant car seat?
Asking the parents to demonstrate how to secure the infant in the car seat
Which statement made by a parent indicates a need for the nurse to provide instruction on safety and accident prevention?
“I’m going to buy a backpack for my 2-week-old baby so I can carry her in it whenever she gets fussy.”
Which statement made by a new mother should be a cause of concern to the nurse?
“I don’t intend to spoil my baby by picking him up every time he cries.”
Which of the following is the appropriate treatment for miliaria?
Removal of excess clothing
An infant who eats very rapidly may experience problems with swallowing excessive air. What should the mother be instructed to do?
Begin the feeding before the infant becomes too hungry.
Which statement is true regarding growth and development during the first 6 months?
The infant will gain about 2 lb per month
Infant immunizations should begin at which age?
Birth
Which clinical finding indicates a sign of illness in the newborn?
An axillary temperature greater than 38°C (100.4°F)
During the first 6 months of life, the infant should have well-baby checkups at which interval?
1 to 2 months
As the nurse assists a newly discharged patient and her infant to the waiting car, the nurse notes that the infant seat is in the front seat of the car facing the front and secured by the seat belt. The nurse should explain to the parents that the car seat should be placed
in the back seat facing the rear of the car.
Which statement by a parent suggests that the nurse intervene with further teaching?
My 5-month-old infant has been drooling, biting, and running a fever for the past few days. I think he’s teething.”
A new mother asks what she can do to help her infant sleep through the night. Which should the nurse suggest?
Avoid talking to the infant and keep the room quiet during night feedings.
A new mother asks, “Why should I bring my baby in for a checkup? He is not sick.” Which is the nurse’s best response?
“Well-baby visits allow the doctor to determine whether your baby is growing and developing normally.”
Which infant should be seen immediately by a health care provider?
A 2-week-old infant with nasal congestion and respirations of 64 breaths per minute
Which intervention should be included in the home care of a high-risk infant?
Providing continued respiratory support and oxygen
Which statement by the parents indicates the need for further education with regard to pacifier use?
We will keep track of the pacifier by tying it to a string around the baby’s neck.”
The nurse is calling a new mother to schedule a routine home visit planned for 48 to 72 hours after discharge. What is the nurse’s priority question to help determine the best time for the visit?
“At approximately what time do you think you will be nursing your baby?”
A new mother is preparing for discharge from the birthing center and relays to the nurse her concerns about how she will handle the baby’s episodes of crying. What is the nurse’s best response?
Crying is the way your baby communicates with you. It is important for you to meet your baby’s needs consistently and promptly.”
During a prenatal education class regarding infant home care, the nurse is reviewing the simulated setting created by new mothers for putting the baby to bed. Which observation indicates to the nurse that the new mothers understood the nurse’s teaching about infant safety?
The baby mannequin is in the supine position.
The nurse is teaching new parents strategies to help with newborn colic. Which interventions should the nurse suggest? (Select all that apply.)
Feed the infant in an upright position.
Burp the infant frequently during feedings.
Increase carrying time by use of a front carrier pack.
Parents ask the nurse, “How many wet diapers a day should we expect and how will we know the baby’s stools are normal?” Which response should the nurse make if the infant is being formula fed? (Select all that apply.)
The infant should have at least one stool a day.
The infant should have at least six wet diapers a day.
The nurse is teaching new parents how to avoid and treat newborn diaper rash. Which should the nurse include in the teaching session? (Select all that apply.)
Keep the diaper area clean and dry.
Do not use talc-based powders in the diaper area.
Remove the diaper and expose the perineum to warm air if a rash develops.
The nurse is preparing a newborn for a circumcision. Which prescribed interventions should the nurse implement to alleviate pain? (Select all that apply)
Oral sucrose during the procedure
Acetaminophen (Tylenol) postprocedure, as needed
EMLA cream (eutectic mixture of local anesthetics) before the procedure
The nurse has just completed discharge teaching to parents on newborn bathing. Which statement made by the parents indicates a further need for teaching? (Select all that apply.)
We will use cotton-tipped swabs to clean the ears.”
“We will use an antibacterial soap during the sponge bath.”
The breastfeeding patient should be taught a safe method to remove her breast from the baby’s mouth. Which suggestion by the nurse is most appropriate?
Break the suction by inserting your finger into the corner of the infant’s mouth.
Which woman is most likely to continue breastfeeding beyond 6 months?
A woman who avoids using bottles.
In which condition is breastfeeding contraindicated?
Human immunodeficiency virus infection
Which type of formula should not be diluted before being administered to an infant?
Ready to use
How many kilocalories per kilogram (kcal/kg) of body weight does a full-term formula-fed infant need each day?
100 to 110
Which hormone is essential for milk production?
Prolactin
Which recommendation should the nurse make to a patient to assist in initiating the milk-ejection reflex?
Place the infant to the breast.
Which is the first step in assisting the breastfeeding mother to nurse her infant?
Assess the woman’s knowledge of breastfeeding.
Which of the following is an important consideration in positioning a newborn for breastfeeding?
Placing the infant at nipple level facing the breast
The patient should be taught that when her infant falls asleep after feeding for only a few minutes, she should do which of the following?
Unwrap and gently arouse the infant.
To prevent breast engorgement, what should the new breastfeeding mother be instructed to do?
Breast-feed frequently and for adequate lengths of time.
As the nurse assists a new mother with breastfeeding, the mother asks, “If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?” The nurse’s best response is that it contains
important immunoglobulins.
How should the nurse explain milk supply and demand when responding to the question, “Will I produce enough milk for my baby as she grows and needs more milk at each feeding?”
The mother’s milk supply will increase as the infant demands more at each feeding.
Which technique should the nurse recommend to the postpartum patient in order to prevent nipple trauma?
Position the infant so the nipple is far back in the mouth.
A breastfeeding patient who was discharged yesterday calls to ask about a tender hard area on her right breast. What should the nurse’s first response be?
Try massaging the area and apply heat; it is probably a plugged duct.”
Which is an important consideration regarding the storage of breast milk?
Can be kept refrigerated for 4 days
What is the most serious consequence of propping an infant’s bottle?
Aspiration
A new mother asks why she has to open a new bottle of formula for each feeding. What is the nurse’s best response?
Bacteria can grow rapidly in warm milk.”
A new mother asks whether she should feed her newborn colostrum because it is not “real milk.” The nurse’s best answer includes which information?
Colostrum is high in antibodies, protein, vitamins, and minerals.
A mother is breastfeeding her newborn son and is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The ideal nursing response would be to
have the patient put the infant to her breast more frequentl
A mother is attempting to breastfeed her infant in the hospital setting. The infant is sleepy and displays some audible swallowing, the maternal nipples are flat, and the breasts are soft. The nurse has attempted to teach the mother positioning on one side, and now the mother wants to place the infant to the breast on the other side. Based on LATCH scores, what score would the nurse assign to this feeding session?
6 and further teach and assist the mother in feeding activities.
A mother conveys concern over the fact that she is not certain if her newborn is receiving enough nutrients from breastfeeding. This is the baby’s first clinic visit after birth. What information can you provide that will help alleviate her fears regarding nutrient status for her newborn?
Monitor the infant’s output; as long as at least six or more diapers are changed in a 24-hour period, the baby is receiving sufficient intake.
A breastfeeding mother asks the postpartum nurse if any supplementation is necessary once her breast milk comes in. What is the nurse’s most appropriate response?
“Breast milk is low in vitamin D and supplementation with 400 IU is
A new mother is preparing for discharge. She plans on bottle feeding her baby. Which statement indicates to the nurse that the mom needs more information about bottle feeding?
“I should encourage my baby to consume the entire amount of formula prepared for each feeding.”
The nurse is teaching a postpartum patient different holds for breastfeeding. Which of the following figures depicts the football hold frequently used for patients who have had a cesarean birth?
B
Late in pregnancy, the patient’s breasts should be evaluated by the nurse to identify any potential concerns related to breastfeeding. Which of the following nipple conditions make it necessary to intervene prior to birth. (Select all that apply.)
Flat nipples
Inverted nipples
Nipples that contract when compressed
For which infant should the nurse anticipate the use of soy formula? (Select all that apply.)
Infant with galactosemia
Infant with lactase deficiency
Infant with a malabsorption disorder
A new mother asks the nurse, “How will I know early signs of hunger in my baby?” The nurse’s best response is which of the following? (Select all that apply.)
Rooting
Lip smacking
Sucking on the hands
Which is the most useful factor in preventing premature birth?
Adequate prenatal care
In comparison with the term infant, the preterm infant has
greater surface area in proportion to weight.
Decreased surfactant production in the preterm lung is a problem because
surfactant keeps the alveoli open during expiration.
A preterm infant is on a ventilator, with intravenous lines and other medical equipment. When the parents come to visit for the first time, what is the most important action by the nurse?
Encourage the parents to touch their infant.
Which preterm infant should receive gavage feedings instead of bottle feedings?
Has a sustained respiratory rate of 70 breaths per minute
Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem?
Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.
A characteristic of a post-term infant who weighs 7lb, 12oz, and who lost weight in utero, is
lack of subcutaneous fat.
In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level?
Retinopathy of prematurity (ROP)
In caring for the post-term infant, thermoregulation can be a concern, especially in an infant who also has a(n)
blood glucose level of 25 mg/dL.
Which statement regarding newborns classified as small for gestational age (SGA) is accurate?
They are below the tenth percentile on gestational growth charts.
Which nursing action is especially important for an SGA newborn?
Prevent hypoglycemia with early and frequent feedings.
What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction?
The head seems large compared with the rest of the body
Which data should alert the nurse caring for an SGA infant that additional calories may be needed?
Three successive temperature measurements were 36.1C, 35.5C, and 36.1C (97, 96, and 97F).
Which statement regarding large-for-gestational age (LGA) infants is most accurate?
They are prone to hypoglycemia, polycythemia, and birth injuries.
Following the vaginal birth of a macrosomic infant, the nurse should evaluate the infant for
clavicle fractures.
An infant delivered prematurely at 28 weeks gestation weighs 1200g. Based on this information the infant is classified as
VLBW.
The nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respirations. The infant’s color and heart rate remain unchanged. The nurse suspects that the infan
is experiencing periodic breathing episodes and will require continuous monitoring while in the nursery unit.
Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette?
Fluid volume deficit related to phototherapy treatment
An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable and muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of
PIVH.
Following a traumatic birth of a 10lb infant, the nurse should evaluate
flexion of both upper extremities.
A newborn assessment finding that would support the nursing diagnosis of postmaturity would be
loose skin.
Because late preterm infants are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these infants are at increased risk for which of the following? (Select all that apply.)
Sepsis
Hyperbilirubinemia
Problems with thermoregulation
The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. If breastfeeding must be supplemented, formula should be used instead of water. The purpose of this plan is to
provide fluids and protein.
Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority?
Test for the blood glucose level.
Which newborn should the nurse recognize as being at the greatest risk for developing respiratory distress syndrome?
A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes.
Transitory tachypnea of the newborn (TTN) is thought to occur as a result of
inadequate absorption of fetal lung fluid.
The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of
persistent pulmonary hypertension.
The nurse present at the birth is reporting to the nurse who will be caring for the neonate after the delivery. Prior to birth there was meconium present in the amniotic fluid. The infant presented with depressed respirations and weak muscle tone. Which information should be included in the report for this infant?
The infant required warmed humidified oxygen.
Which intervention will increase the effectiveness in reducing the indirect bilirubin in an affected newborn?
Turn the infant every 2 hours.
Newborns whose mothers are substance abusers frequently exhibit which of the following behaviors?
Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding
When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find
signs of congestive heart failure.
In an infant with cyanotic cardiac anomaly, the nurse should expect to see
little to no improvement in color with oxygen administration.
The difference between nonphysiologic jaundice (pathologic jaundice) and physiologic jaundice is that nonphysiologic jaundice
appears during the first 24 hours of life.
Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring and slight retractions are noted. The newborn is admitted to the neonatal intensive care unit (NICU) for closer observation, with a diagnosis of transient tachypnea of the neonate (TTN). The parents are notified and become anxious because they have no understanding of what this means for their infant. The best action that the nurse can take at this time is to
explain to them that this often occurs following a birth and it will most likely resolve in the next 24 to 48 hours.
While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth?
Risk for aspiration related to retained secretions
Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant?
Infant bilirubin level
Which of the following lab values indicates that an infant may have polycythemia?
Hct 70%
The nurse notes that the infant has been feeding poorly over the last 24 hours. The nurse should immediately assess for other signs of
neonatal infection.
The priority assessment for the Rh-negative infant whose mother’s indirect Coombs test was positive at 36 weeks is
skin color.
The nurse should be alert to a blood group incompatibility if
mother is B-positive and infant is O-negative.
Infection can be transmitted to the neonate from mother during the pregnancy or birth or from the mother, family members, visitors, or agency staff after birth. Which viral infections are most likely to be transmitted during the birth process? (Select all that apply.)
Hepatitis B
HIV
Herpes
Cytomegalovirus
The drug-exposed infant often presents with irritability, frantic crying, and is difficult to console. Which nursing measures can be used to prevent this behavior in this high-risk infant? (Select all that apply.)
Swaddle the infant.
Rock slowly and gently.
Coo softly and gently.
Which contraceptive method provides protection against sexually transmitted diseases?
Male or female condoms
A nurse is leading a discussion regarding options for birth control. Which of the following methods is considered the most reliable?
Intrauterine device
Which patient is a safe candidate for the use of oral contraceptives?
43-year-old who does not smoke cigarettes.
The role of the nurse in family planning is to
educate couples on the various methods of contraception.
Informed consent concerning contraceptive use is important since some of the methods
have potentially dangerous side effects.
Which contraceptive method should be contraindicated in a patient with a history of toxic shock syndrome?
Cervical cap
When instructing a patient in the use of spermicidal foam or gel, it is important to include the information that
douching should be avoided for at least 6 hours.
Which symptom in a patient using oral contraceptives should be reported to the physician immediately?
Leg pain and edema
When using the basal body temperature method of family planning, the woman should understand that
her temperature will increase about 0.2 to 0.4°C (0.4 to 0.8°F) after ovulation.
The major difference between the diaphragm and the cervical cap is that the diaphragm
applies pressure on the urethra.
The patient who has had an intrauterine device (IUD) inserted should be instructed to
check the placement of the string once a week for 4 weeks.
A male patient asks, “Why do I have to use another contraceptive? I had a vasectomy last week.” The best response is
Complete sterilization doesn’t occur until all sperm have left the system.”
A woman who has a successful career and a busy lifestyle will most likely look for which type of contraceptive?
Is the easiest and most convenient to use
The method of contraception that is considered the safest for women is a(n)
male condom.
A patient is 27 years old and delivered her first baby yesterday. She and her husband do not want to have another baby for at least 3 to 4 years. The most appropriate method of birth control to meet their needs is
combination of condoms and foam.
The most appropriate statement for introducing the topic of family planning in the postpartum setting is
What are your plans for future pregnancies?”
In reviewing information related to the occurrence of pregnancies using a focus group discussion with women, concern was expressed that many of them had problems using their respective type of contraception. As a result of noncompliance issues several women became pregnant. Based on this information, the nurse would incorporate which of the following in a teaching plan for group members?
Plan for assessing the patients’ knowledge related to the contraception methods and provide information to increase the knowledge base so that the effectiveness rate would improve.
You are teaching a group of adolescents regarding myths and facts related to contraception. Which statement indicates that additional teaching is needed for this group?
The withdrawal technique provides a higher likelihood that a teen will not get pregnant.
A patient presents to the Women’s Health Clinic for continuation of her contraceptive method. She has been using Depo-Provera (medroxyprogesterone acetate) for 24 months. In preparation for instituting a plan of care, the nurse would consider which option as a priority?
Obtain information for an alternate contraception method.
Which of the following statements is correct regarding the use of contraception and the occurrence of sexually transmitted diseases (STDs)?
Barrier methods, if used correctly, are more likely to protect individuals from STDs as compared with other contraceptive method
Which of the following is a potential disadvantage for the patient who wishes to use an intrauterine device (IUD) as a method of birth control?
Ectopic pregnancy
A patient is using Depo-Provera as her method of birth control. Which clinical finding warrants immediate intervention by the nurse?
Mid-cycle bleeding
A patient has had a prior history of endometriosis and comes to the clinic asking about which method of birth control might be helpful to alleviate her symptoms. Which birth control method would provide the greatest benefit to this patient?
Oral contraceptives
You are evaluating a patient in the clinic setting who has been taking oral contraceptives for several years, without side effects. Vital signs are stable and the patient denies any pain or tenderness. On examination, you note a small erythematous area of approximately 2 cm on her right lower leg. She denies any traumatic injury and says this is a recent onset of a few days. Based on this information you would
refer the patient to the health care provider for additional diagnostic work up.