NURSING MISC|Maternity Exam 2|Test Bank (Latest 2020) A+ Guide;Northeastern University

Maternity Exam 2 The nurse is caring for a pregnant woman who admits to using cocaine and ecstasy on a regular basis. The client states, "Everybody knows that alcohol is bad during pregnancy, but what's the big deal abo ...

Maternity Exam 2 The nurse is caring for a pregnant woman who admits to using cocaine and ecstasy on a regular basis. The client states, "Everybody knows that alcohol is bad during pregnancy, but what's the big deal about ecstasy?" What is the nurse's best response? 1. "Ecstasy can cause a high fever in you and therefore cause the baby harm." 2. "Ecstasy leads to deficiencies of thiamine and folic acid, which help the baby develop." 3. "Ecstasy produces babies with small heads and short bodies with brain function alterations." 4. "Ecstasy produces intrauterine growth restriction and meconium aspiration." The nurse is doing preconception counseling with a 28-year-old woman with no prior pregnancies. Which statement made by the client indicates to the nurse that the client has understood the teaching? 1. "I can continue to drink alcohol until I am diagnosed as pregnant." 2. "I need to stop drinking alcohol completely when I start trying to get pregnant." 3. "A beer once a week will not damage the fetus." 4. "I can drink alcohol while breastfeeding because it doesn't pass into breast milk." A woman's history and appearance suggest drug abuse. What is the nurse's best approach? 1. Ask the woman directly, "Do you use any street drugs?" 2. Ask the woman whether she would like to talk to a counselor. 3. Ask some questions about over-the-counter medications and avoid mention of illicit drugs. 4. Explain how harmful drugs can be for her baby. A 20-year-old woman is at 28 weeks' gestation. Her prenatal history reveals past drug abuse, and urine screening indicates that she has recently used heroin. The nurse should recognize that the woman is at increased risk for which condition? 1. Erythroblastosis fetalis 2. Diabetes mellitus 3. Abruptio placentae 4. Pregnancy-induced hypertension The nurse is working with a woman who abuses stimulants. The nurse is aware that the fetus is at risk for which of the following? Select all that apply. 1. Withdrawal symptoms 2. Cardiac anomalies 3. Sudden infant death syndrome 4. Being small for gestational age 5. Fetal alcohol syndrome The nurse is assessing a woman at 10 weeks' gestation who is addicted to alcohol. The woman asks the nurse, "What is the point of stopping drinking now if my baby probably has been hurt by it already?" What is the best response by the nurse? 1. "It won't help your baby, but you will feel better during your pregnancy if you stop now." 2. "If you stop now, you and your baby have less chance of serious complications." 3. "If you limit your drinking to once a week, your baby will be okay." 4. "You might as well stop it now, because once your baby is born, you'll have to give up alcohol if you plan on breastfeeding." The client has just been diagnosed as diabetic. The nurse knows teaching was effective when the client makes which statement? 1. "Ketones in my urine mean that my body is using the glucose appropriately." 2. "I should be urinating frequently and in large amounts to get rid of the extra sugar." 3. "My pancreas is making enough insulin, but my body isn't using it correctly." 4. "I might be hungry frequently because the sugar isn't getting into the tissues the way it should." The client with insulin-dependent type 2 diabetes and an HbA1c of 5.0% is planning to become pregnant soon. What anticipatory guidance should the nurse provide this client? 1. Insulin needs decrease in the first trimester and usually begin to rise late in the first trimester as glucose use and glycogen storage by the woman and fetus increase. 2. The risk of ketoacidosis decreases during the length of the pregnancy. 3. Vascular disease that accompanies diabetes slows progression. 4. The baby is likely to have a congenital abnormality because of the diabetes. A newly diagnosed insulin-dependent type 1 diabetic with good blood sugar control is at 20 weeks' gestation. She asks the nurse how her diabetes will affect her baby. What would the best explanation include? 1. "Your baby could be smaller than average at birth." 2. "Your baby will probably be larger than average at birth." 3. "As long as you control your blood sugar, your baby will not be affected at all." 4. "Your baby might have high blood sugar for several days." A 26-year-old client is 28 weeks pregnant. She has developed gestational diabetes. She is following a program of regular exercise, which includes walking, bicycling, and swimming. What instructions should be included in a teaching plan for this client? 1. "Exercise either just before meals or wait until 2 hours after a meal." 2. "Carry hard candy (or other simple sugar) when exercising." 3. "If your blood sugar is 120 mg/dL, eat 20 g of carbohydrate." 4. "If your blood sugar is more than 120 mg/dL, drink a glass of whole milk." A 26-year-old client is 26 weeks pregnant. Her previous births include two large-for-gestational-age babies and one unexplained stillbirth. Which tests would the nurse anticipate as being most definitive in diagnosing gestational diabetes? 1. A 50g, 1-hour glucose screening test 2. A single fasting glucose level 3. A 100g, 1-hour glucose tolerance test 4. A 100g, 3-hour glucose tolerance test A client with diabetes is receiving preconception counseling. The nurse will emphasize that during the first trimester, the woman should be prepared for which of the following? 1. The need for less insulin than she normally uses 2. Blood testing for anemia 3. Assessment for respiratory complications 4. Assessment for contagious conditions The nurse has written the nursing diagnosis Injury, Risk for a diabetic pregnant client. Interventions for this diagnosis include which of the following? Select all that apply. 1. Assessment of fetal heart tones 2. Perform oxytocin challenge test, if ordered 3. Refer the client to a diabetes support group 4. Assist with the biophysical profile assessment 5. Develop an appropriate teaching plan A diabetic client goes into labor at 36 weeks' gestation. Provided that tests for fetal lung maturity are successful, the nurse will anticipate which of the following interventions? Select all that apply. 1. Administration of tocolytic therapy 2. Beta-sympathomimetic administration 3. Allowance of labor to progress 4. Hourly blood glucose monitoring 5. Cesarean birth may be indicated if evidence of reassuring fetal status exists A woman asks her nurse what she can do before she begins trying to get pregnant to help her baby, as she is prone to anemia. What would the nurse correctly advise her to do? 1. Get pregnant, then start iron supplementation. 2. Add more carbohydrates to her diet. 3. Begin taking folic acid supplements daily. 4. Have a hemoglobin baseline done now so her progress can be followed. The client with thalassemia intermedia has a hemoglobin level of 9.0. The nurse is preparing an education session for the client. Which statement should the nurse include? 1. "You need to increase your intake of meat and other iron-rich foods." 2. "Your low hemoglobin could put you into preterm labor." 3. "Increasing your vitamin C intake will help your hemoglobin level." 4. "You should not take iron supplements." The client at 20 weeks' gestation has had an ultrasound that revealed a neural tube defect in her fetus. The client's hemoglobin level is 8.5. The nurse should include which statement when discussing these findings with the client? 1. "Your low iron intake has caused anemia, which leads to the neural tube defect." 2. "You should increase your vitamin C intake to improve your anemia." 3. "You are too picky about food. Your poor diet caused your baby's defect." 4. "You haven't had enough folic acid in your diet. You should take a supplement." The clinic nurse is teaching a pregnant client about her iron supplement. Which information is included in the teaching? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Iron does not affect the gastrointestinal tract. 2. A stool softener might be needed. 3. Start a low dose, and increase it gradually. 4. Expect the stools to be black and bloody. 5. Iron absorption is poor if taken with meals. The client at 9 weeks' gestation has been told that her HIV test was positive. The client is very upset, and tells the nurse, "I didn't know I had HIV! What will this do to my baby?" The nurse knows teaching has been effective when the client makes which statement? 1. "I cannot take the medications that control HIV during my pregnancy, because they will harm the baby." 2. "My baby can get HIV during the pregnancy and through my breast milk." 3. "The pregnancy will increase the progression of my disease and will reduce my CD4 counts." 4. "The HIV won't affect my baby, and I will have a low-risk pregnancy without additional testing." During the history, the client admits to being HIV-positive and says she knows that she is about 16 weeks pregnant. Which statements made by the client indicate an understanding of the plan of care both during the pregnancy and postpartally? Select all that apply. 1. "During labor and delivery, I can expect the zidovudine (ZDV) to be given in my IV." 2. "After delivery, the dose of zidovudine (ZDV) will be doubled to prevent further infection." 3. "My baby will be started on zidovudine (ZDV) for six weeks following the birth." 4. "My baby's zidovudine (ZDV) will be given in a cream form." 5. "My baby will not need zidovudine (ZDV) if I take it during my pregnancy." A woman is 32 weeks pregnant. She is HIV-positive but asymptomatic. The nurse knows what would be important in managing her pregnancy and delivery? 1. An amniocentesis at 30 and 36 weeks 2. Weekly non-stress testing beginning at 32 weeks' gestation 3. Application of a fetal scalp electrode as soon as her membranes rupture in labor 4. Administration of intravenous antibiotics during labor and delivery A pregnant woman is married to an intravenous drug user. She had a negative HIV screening test just after missing her first menstrual period. What would indicate that the client needs to be retested for HIV? 1. Hemoglobin of 11 g/dL and a rapid weight gain 2. Elevated blood pressure and ankle edema 3. Shortness of breath and frequent urination 4. Persistent candidiasis The nurse is evaluating the goal "Client will remain free of opportunistic infections" for an HIV-positive pregnant client. The nurse determines the goal was met when the client has which of the following? Select all that apply. 1. An absolute CD4+ T-lymphocyte count below 200 2. No complaint of chills or fever during the pregnancy 3. Weight gain of 30 lbs during the pregnancy 4. ESR above 20 mm/hr 5. Normal erythrocyte sedimentation rate maintained during the pregnancy Women with HIV should be evaluated and treated for other sexually transmitted infections and for what condition occurring more commonly in women with HIV? 1. Syphilis 2. Toxoplasmosis 3. Gonorrhea 4. Herpes A 21-year-old at 12 weeks' gestation with her first baby has known cardiac disease, class III, as a result of childhood rheumatic fever. During a prenatal visit, the nurse reviews the signs of cardiac decompensation with her. The nurse will know that the client understands these signs and symptoms if she states that she would notify her doctor if she had which symptom? 1. "A pulse rate increase of 10 beats per minute" 2. "Breast tenderness" 3. "Mild ankle edema" 4. "A frequent cough" A client is at 12 weeks' gestation with her first baby. She has cardiac disease, class III. She states that she had been taking sodium warfarin (Coumadin), but her physician changed her to heparin. She asks the nurse why this was done. What should the nurse's response be? 1. "Heparin is used when coagulation problems are resolved." 2. "Heparin is safer because it does not cross the placenta." 3. "They are the same drug, but heparin is less expensive." 4. "Coumadin interferes with iron absorption in the intestines." A 21-year-old woman is at 12 weeks' gestation with her first baby. She has cardiac disease, class III, as a result of having had childhood rheumatic fever. Which planned activity would indicate to the nurse that the client needs further teaching? 1. "I will be sure to take a rest period every afternoon." 2. "I would like to take childbirth education classes in my last trimester." 3. "I will have to cancel our trip to Disney World." 4. "I am going to start my classes in water aerobics next week." Which of the following symptoms, if progressive, are indicative of CHF, the heart's signal of its decreased ability to meet the demands of pregnancy? Select all that apply. 1. Palpitations 2. Heart murmurs 3. Dyspnea 4. Frequent urination 5. Rales The nurse is evaluating the plan of care for a pregnant client with a heart disorder. The nurse concludes that the plan was successful when data indicate which of the following? Select all that apply. 1. The client gave birth to a healthy baby. 2. The client did not develop congestive heart failure. 3. The client developed thromboembolism. 4. The client identified manifestations of potential complications. 5. The client can identify her condition and its impact on her pregnancy, labor and birth, and postpartum period. The renatal clinic nurse has received four phone calls. Which client should the nurse call back first 1. Pregnant woman at 28 weeks with history of asthma who is reporting difficulty breathing an shortness of breath 2. Pregnant woman at 6 weeks with a seizure disorder who is inquiring which foods are good folc acid sources for her 3. Pregnant woman at 35 weeks with a positive HBsAG who is wondering what treatment her baby will receive after birth 4. Pregnant woman at 11 weeks with untreated hyperthyroidism who is describing the onset of vaginal bleeding The nurse is working with a pregnant woman who has systemic lupus erythematosus (SLE). What does the nurse anticipate the infant might be born with? Select all that apply. 1. A tendency to bleed excessively 2. An increased chance of developing infections 3. A hemoglobin less than optimal for good health 4. Problems with vision 5. Hearing loss A pregnant asthmatic client is being seen for her initial prenatal visit. The nurse knows that the fetal implications of maternal asthma include which of the following? Select all that apply. 1. Prematurity 2. Low birth weight 3. Hypoxia with maternal exacerbation 4. Congenital anomalies from the medications 5. Perinatal transfer of the asthma While doing a prenatal assessment on a woman who has hepatitis B and intends to become pregnant, the nurse explains the impact of the hepatitis B on pregnancy and birth. Which statement does the nurse include in the teaching? 1. "Your baby contracted hepatitis B from you when she was conceived." 2. "Don't worry about your baby during the birth. You're more likely to be affected then by the hepatitis B." 3. "Your baby will be immune to your hepatitis B." 4. "Hepatitis B does not usually affect the course of pregnancy." The nurse is caring for a client who was just admitted to rule out ectopic pregnancy. Which orders are the most important for the nurse to perform? Select all that apply. 1. Assess the client's temperature. 2. Document the time of the client's last meal. 3. Obtain urine for urinalysis and culture. 4. Report complaints of dizziness or weakness. 5. Have the lab draw blood for B-hCG level every 48 hours. The nurse educator is presenting a class on the different kinds of miscarriages. Miscarriages, or spontaneous abortions, are classified clinically into which of the following different categories? Select all that apply. 1. Threatened bortion 2. Incomplee abortion 3. Complete abortion 4. Missed abortin 5. Acute abortion The nurse is presenting a class on the pathophysiology of the different abortions. Some of the causes are which of the following? Select all that apply. 1. Chromosomal abnormalities 2. Insufficient or excessive hormonal levels 3. Sexual intercourse in the first trimester 4. Infections in the first trimester 5. Cervical insufficiency A woman is hospitalized with severe preeclampsia. The nurse is meal-planning with the client and encourages a diet that is high in what? 1. Sodium 2. Carbohydrates 3. Protein 4. Fruits The nurse is assessing a client who has severe preeclampsia. What assessment finding should be reported to the physician? 1. Excretion of less than 300 mg of protein in a 24-hour period 2. Platelet count of less than 100,000/mm3 3. Urine output of 50 mL per hour 4. 12 respirations A woman is 16 weeks pregnant. She has had cramping, backache, and mild bleeding for the past 3 days. Her physician determines that her cervix is dilated to 2 centimeters, with 10% effacement, but membranes are still intact. She is crying, and says to the nurse, "Is my baby going to be okay?" In addition to acknowledging the client's fear, what should the nurse also say? 1. "Your baby will be fine. We'll start IV, and get this stopped in no time at all." 2. "Your cervix is beginning to dilate. That is a serious sign. We will continue to monitor you and the baby for now." 3. "You are going to miscarry. But you should be relieved because most miscarriages are the result of abnormalities in the fetus." 4. "I really can't say. However, when your physician comes, I'll ask her to talk to you about it." The nurse is supervising care in the emergency department. Which situation most requires an intervention? 1. Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer's solution running at 125 mL/hour 2. Spotting of pinkish-brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour 3. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20 4. Dark red bleeding at 30 weeks' gestation with normal vital signs; client reports an absence of fetal movement A client who is 11 weeks pregnant presents to the emergency department with complaints of dizziness, lower abdominal pain, and right shoulder pain. Laboratory tests reveal a beta-hCG at a lower-than-expected level for this gestational age. An adnexal mass is palpable. Ultrasound confirms no intrauterine gestation. The client is crying and asks what is happening. The nurse knows that the most likely diagnosis is an ectopic pregnancy. Which statement should the nurse include? 1. "You're feeling dizzy because the pregnancy is compressing your vena cava." 2. "The pain is due to the baby putting pressure on nerves internally." 3. "The baby is in the fallopian tube; the tube has ruptured and is causing bleeding." 4. "This is a minor problem. The doctor will be right back to explain it to you." A client at 18 weeks' gestation has been diagnosed with a hydatidiform mole. In addition to vaginal bleeding, which signs or symptoms would the nurse expect to see? Select all that apply. 1. Hyperemesis gravidarum 2. Diarrhea and hyperthermia 3. Uterine enlargement greater than expected 4. Polydipsia 5. Vaginal bleeding A woman at 7 weeks' gestation is diagnosed with hyperemesis gravidarum. Which nursing diagnosis would receive priority? 1. Fluid Volume: Deficient 2. Cardiac Output, Decreased 3. Injury, Risk for 4. Nutrition, Imbalanced: Less than Body Requirements The prenatal clinic nurse is caring for a client with hyperemesis gravidarum at 14 weeks' gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first? 1. Weigh the client. 2. Give 1 liter of lactated Ringer's solution IV. 3. Administer 30 mL Maalox (magnesium hydroxide) orally. 4. Encourage clear liquids orally. A pregnant client has been admitted with a diagnosis of hyperemesis. Which orders written by the primary healthcare provider are the highest priorities for the nurse to implement? Select all that apply. 1. Obtain complete blood count. 2. Start intravenous fluid with multivitamins. 3. Check admission weight. 4. Obtain urine for urinalysis. 5. Give a medication to stop the nausea and vomiting. A primary herpes simplex infection in the first trimester can increase the risk of which of the following? 1. Spontaneous abortion 2. Preterm labor 3. Intrauterine growth restriction 4. Neonatal infection A woman is being treated for preterm labor with magnesium sulfate. The nurse is concerned that the client is experiencing early drug toxicity. What assessment finding by the nurse indicates early magnesium sulfate toxicity? 1. Patellar reflexes weak or absent 2. Increased appetite 3. Respiratory rate of 16 4. Fetal heart rate of 120 Doppler flow studies (umbilical velocimetry) help to assess which of the following? 1. Placental function and sufficiency 2. Fetal heart rate 3. Fetal growth and fluid levels 4. Maturity of the fetal lungs When blood pressure and other signs indicate that the preeclampsia is worsening, hospitalization is necessary to monitor the woman's condition closely. At that time, which of the following should be assessed? Select all that apply. 1. Fetal heart rate 2. Blood pressure 3. Temperature 4. Urine color 5. Pulse and respirations The community nurse is working with a client at 32 weeks' gestation who has been diagnosed with preeclampsia. Which statement by the client would indicate that additional information is needed? 1. "I should call the doctor if I develop a headache or blurred vision." 2. "Lying on my left side as much as possible is good for the baby." 3. "My urine could become darker and smaller in amount each day." 4. "Pain in the top of my abdomen is a sign my condition is worsening." Infants of women with preeclampsia during pregnancy tend to be small for gestational age (SGA) because of which condition? 1. Intrauterine growth restriction 2. Oliguria 3. Proteinuria 4. Hypertension A woman is experiencing preterm labor. The client asks why she is on betamethasone. Which is the nurse's best response? 1. "This medication will halt the labor process until the baby is more mature." 2. "This medication will relax the smooth muscles in the infant's lungs so the baby can breathe." 3. "This medication is effective in stimulating lung development in the preterm infant." 4. "This medication is an antibiotic that will treat your urinary tract infection, which caused preterm labor." A client is being admitted to the labor area with the diagnosis of eclampsia. Which actions by the nurse are appropriate at this time? Select all that apply. 1. Tape a tongue blade to the head of the bed. 2. Pad the side rails. 3. Have the woman sit up. 4. Provide the client with grief counseling. 5. The airway should be maintained and oxygen administered. A clinic nurse is planning when to administer Rh immune globulin (RhoGAM) to an Rh-negative pregnant client. When should the first dose of RhoGAM be administered? 1. After the birth of the infant 2. 1 month postpartum 3. During labor 4. At 28 weeks' gestation Whether sensitization is the result of a blood transfusion or maternal-fetal hemorrhage for any reason, what test can be performed to determine the amount of Rh(D) positive blood present in the maternal circulation and to calculate the amount of Rh immune globulin needed? 1. Indirect Coombs' test 2. Nonstress test 3. Kleihauer-Betke or rosette test 4. Direct Coombs' test Which maternal-child client should the nurse see first? 1. Blood type O, Rh-negative 2. Indirect Coombs' test negative 3. Direct Coombs' test positive 4. Blood type B, Rh-positive The client with blood type A, Rh-negative, delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective? 1. "I need to get RhoGAM so I don't have problems with my next pregnancy." 2. "Because my baby is Rh-positive, I don't need RhoGAM." 3. "If my baby had the same blood type I do, it might cause complications." 4. "Before my next pregnancy, I will need to have a RhoGAM shot." A client is concerned because she has been told her blood type and her baby's are incompatible. What is the nurse's best response? 1. "This is called ABO incompatibility. It is somewhat common but rarely causes significant hemolysis." 2. "This is a serious condition, and additional blood studies are currently in process to determine whether you need a medication to prevent it from occurring with a future pregnancy." 3. "This is a condition caused by a blood incompatibility between you and your husband, but does not affect the baby." 4. "This type of condition is very common, and the baby can receive a medication to prevent jaundice from occurring." If the woman is Rh negative and not sensitized, she is given Rh immune globulin to prevent what? 1. The potential for hemorrhage 2. Hyperhomocysteinemia 3. Antibody formation 4. Tubal pregnancy The client presents to the clinic for an initial prenatal examination. She asks the nurse whether there might be a problem for her baby because she has type B Rh-positive blood and her husband has type O Rh-negative blood, or because her sister's baby had ABO incompatibility. What is the nurse's best answer? Select all that apply. 1. "Your baby would be at risk for Rh problems if your husband were Rh-negative." 2. "Rh problems only occur when the mother is Rh-negative and the father is not." 3. "ABO incompatibility occurs only after the baby is born." 4. "We don't know for sure, but we can test for ABO incompatibility." 5. "Your husband's being type B puts you at risk for ABO incompatibility." A woman has a hydatidiform mole (molar pregnancy) evacuated, and is prepared for discharge. The nurse should make certain that the client understands that what is essential? 1. That she not become pregnant until after the follow-up program is completed 2. That she receive RhoGAM with her next pregnancy and birth 3. That she has her blood pressure checked weekly for the next 30 days 4. That she seek genetic counseling with her partner before the next pregnancy A client at 10 weeks' gestation has developed cholecystitis. If surgery is required, what is the safest time during pregnancy? 1. Immediately, before the fetus gets any bigger 2. Early in the second trimester 3. As close to term as possible 4. The risks are too high to do it anytime in pregnancy The nurse is presenting a class to newly pregnant families. What form of trauma will the nurse describe as the leading cause of fetal and maternal death? 1. Falls 2. Domestic violence 3. Gun accidents 4. Motor vehicle accidents During a prenatal exam, a client describes several psychosomatic symptoms and has several vague complaints. What could these behaviors indicate? 1. Abuse 2. Mental illness 3. Depression 4. Nothing, they are normal The nurse is caring for a client at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital would cause the greatest concern? 1. "Blood pressure 110/68, pulse 90." 2. "Entrance wound present below the umbilicus." 3. "Client is positioned in a left lateral tilt." 4. "Clear fluid is leaking from the vagina." The client at 34 weeks' gestation has been stabbed in the low abdomen by her boyfriend. She is brought to the emergency department for treatment. Which statements indicate that the client understands the treatment being administered? Select all that apply. 1. "The baby needs to be monitored to check the heart rate." 2. "My bowel has probably been lacerated by the knife." 3. "I might need an ultrasound to look at the baby." 4. "The catheter in my bladder will prevent urinary complications." 5. "The IV in my arm will replace the amniotic fluid if it is leaking." A client is admitted to the labor suite. It is essential that the nurse assess the woman's status in relation to which infectious diseases? Select all that apply. 1. Chlamydia trachomatis 2. Rubeola 3. Varicella 4. Group B streptococcus 5. Acute pyelonephritis The nurse knows that a mother who has been treated for Beta streptococcus passes this risk on to her newborn. Risk factors for neonatal sepsis caused by Beta streptococcus include which of the following? Select all that apply. 1. Prematurity 2. Maternal intrapartum fever 3. Membranes ruptured for longer than 18 hours 4. A previously infected infant with GBS disease 5. An older mother having her first baby How would the nurse best analyze the results from a client's sonogram that shows the fetal shoulder as the presenting part? 1. Breech, transverse 2. Breech, longitudinal 3. Breech, frank 4. Vertex, transverse A clinic nurse is preparing diagrams of pelvic shapes. Which pelvic shapes are considered least adequate for vaginal childbirth? Select all that apply. 1. Android 2. Anthropoid 3. Gynecoid 4. Platypelloid 5. Lambdoidal suture The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor? Select all that apply. 1. Woman at 7 cm, fetus in general flexion 2. Woman at 3 cm, fetus in longitudinal lie 3. Woman at 4 cm, fetus with transverse lie 4. Woman at 6 cm, fetus at -2 station, mild contractions 5. Woman at 5 cm, fetal presenting part is right shoulder The charge nurse has received the shift change report. Which client requires immediate intervention? 1. Woman at 6 cm undergoing induction of labor, strong contractions every 3 minutes 2. Woman at 4 cm whose fetus is in a longitudinal lie with a cephalic presentation 3. Woman at 10 cm and fetus at +2 station experiencing a strong expulsion urge 4. Woman at 3 cm screaming in fear because her mother died during childbirth Premonitory signs of labor include which of the following? Select all that apply. 1. Braxton Hicks contractions 2. Cervical softening and effacement 3. Weight gain 4. Rupture of membranes 5. Sudden loss of energy A client arrives in the labor and delivery unit and describes her contractions as occurring every 10-12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor. On exam, her cervix is dilated 2 cm, 100% effaced, and -2 station. What best describes this labor? 1. Second phase 2. Latent phase 3. Active phase 4. Transition phase The client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. What is the nurse's best response to the client? 1. "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." 2. "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." 3. "What did you expect? You've only had contractions for a few hours. Labor takes time." 4. "The hormones that cause labor to begin are just getting to be at levels that will change your cervix." A woman who is 40 weeks pregnant calls the labor suite to ask whether she should be evaluated. Which statements by the client indicate she is likely in labor? Select all that apply. 1. "The contractions are 5-20 minutes apart." 2. "I had pink discharge on the toilet paper." 3. "I have had cramping for the past 3-4 hours." 4. "The contractions start in my back and then go to my abdomen and are very intense." 5. "The contractions hurt more when I walk." To identify the duration of a contraction, the nurse would do which of the following? 1. Start timing from the beginning of one contraction to the completion of the same contraction. 2. Time between the beginning of one contraction and the beginning of the next contraction. 3. Palpate for the strength of the contraction at its peak. 4. Time from the beginning of the contraction to the peak of the same contraction. The client at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best? 1. "Unless you have pain with urination, we don't need to worry about it." 2. "These symptoms usually mean the baby's head has descended further." 3. "Come in for an appointment today and we'll check everything out." 4. "This might indicate that the baby is no longer in a head-down position." The client at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make? 1. "You shouldn't work so much at this point in pregnancy." 2. "What you are describing is not commonly experienced in the last weeks." 3. "Your body may be telling you it is going into labor soon." 4. "If the bladder pressure continues, come in to the clinic tomorrow." A client calls the labor and delivery unit and tells the nurse that she is 39 weeks pregnant and that over the last 4 or 5 days, she has noticed that although her breathing has become easier, she is having leg cramps, a slight amount of edema in her lower legs, and an increased amount of vaginal secretions. The nurse tells the client that she has experienced which of the following? 1. Engagement 2. Lightening 3. Molding 4. Braxton Hicks contractions A client who is having false labor most likely would have which of the following? Select all that apply. 1. Contractions that do not intensify while walking 2. An increase in the intensity and frequency of contractions 3. Progressive cervical effacement and dilatation 4. Pain in the abdomen that does not radiate 5. Contractions that lessen with rest and warm tub baths The nurse is preparing a client education handout on the differences between false labor and true labor. What information is most important for the nurse to include? 1. True labor contractions begin in the back and sweep toward the front. 2. False labor often feels like abdominal tightening, or "balling up." 3. True labor can be diagnosed only if cervical change occurs. 4. False labor contractions do not increase in intensity or duration. The nurse is teaching a prenatal class about false labor. The nurse should teach clients that false labor most likely will include which of the following? Select all that apply. 1. Contractions that do not intensify while walking 2. An increase in the intensity and frequency of contractions 3. Progressive cervical effacement and dilatation 4. Pain in the abdomen that does not radiate 5. Contractions are at regular intervals A client is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier that morning. A vaginal exam reveals that her cervix is 100 percent effaced and 8 cm dilated. The nurse knows that the client is in which phase of labor? 1. Active 2. Latent 3. Transition 4. Fourth A client is admitted to the labor unit with contractions 1-2 minutes apart lasting 60-90 seconds. The client is apprehensive and irritable. This client is most likely in what phase of labor? 1. Active 2. Transition 3. Latent 4. Second The client in early labor asks the nurse what the contractions are like as labor progresses. What would the nurse respond? 1. "In normal labor, as the uterine contractions become stronger, they usually also become less frequent." 2. "In ormal labor, as the uterine contractions become stronger, they usually also become less painful. 3. "In normal labor, as the uterine contractions become stronger, they usually also become longer in duration." 4. "In normal labor, as the uterine contractions become stronger, they usually also become shorter in duration." Four minutes after the birth of a baby, there is a sudden gush of blood from the mother's vagina, and about 8 inches of umbilical cord slides out. What action should the nurse take first? 1. Place the client in McRoberts position. 2. Watch for the emergence of the placenta. 3. Prepare for the delivery of an undiagnosed twin. 4. Place the client in a supine position. A nurse needs to evaluate the progress of a woman's labor. The nurse obtains the following data: cervical dilatation 6 cm; contractions mild in intensity, occurring every 5 minutes, with a duration of 30-40 seconds. Which clue in this data does not fit the pattern suggested by the rest of the clues? 1. Cervical dilatation 6 cm 2. Mild contraction intensity 3. Contraction frequency every 5 minutes 4. Contraction duration 30-40 seconds The nurse is caring for a client in labor. Which signs and symptoms would indicate the client is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum 2. ncreased bloody show 3. Sontaneous rupture of the membranes 4. Unontrollable urge to push 5. Inablity to breathe through contractions The labor nurse would not encourage a mother to bear down until the cervix is completely dilated,to prevent which of the following? Select all that apply. 1. Matenal exhaustion 2. Cervical edema 3. Tearing and bruising of the cervix 4. Enhanced perineal thinning 5. Having to perform an episiotomy The nurse is caring for a laboring client. A cervical exam indicates 8 cm dilation. The client is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important? 1. Leave the client alone so she can rest. 2. Ask the family to take a coffee-and-snack break. 3. Encourage the client to have an epidural for pain. 4. Reassure the client that she will not be left alone. During the fourth stage of labor, the client's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse? 1. Turn the client onto her left side. 2. Place the bed in Trendelenburg position. 3. Massage the fundus. 4. Continue to monitor. The nurse has just palpated a laboring woman's contractions. The uterus cannot be indented during a contraction. What would the intensity of these contractions best be characterized as? 1. Weak 2. Mild 3. Moderate 4. Strong The labor and delivery nurse is reviewing charts. The nurse should inform the supervisor about which client? 1. Client at 5 cm requesting labor epidural analgesia 2. Client whose cervix remains at 6 cm for 4 hours 3. Client who has developed nausea and vomiting 4. Client requesting her partner to stay with her Which client requires immediate intervention by the labor and delivery nurse? 1. Client at 8 cm, systolic blood pressure has increased 35 mm Hg 2. Client who delivered 1 hour ago with WBC of 50,000 3. Client at 5 cm with a respiratory rate of 22 between contractions 4. Client in active labor with polyuria The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor? 1. Increased pulse 2. Elevated blood pressure 3. Muscle tension 4. Increased respirations While caring for a client in labor, the nurse notices during a vaginal exam that the fetus's head has rotated internally. What would the nurse expect the next set of cardinal movements for a fetusin a vertex presentation to be? 1. Fleion, extension, restitution, external rotation, and expulsion 2. Explsion, external rotation, and restitution 3. Restiution, flexion, external rotation, and expulsion 4. Extenion, restitution, external rotation, and expulsion When comparing the anterior and posterior fontanelles of a newborn, the nurse knows that both are hat? 1. Both areapproximately the same size 2. Both clos within 12 months of birth 3. Both are ued in labor to identify station 4. Both allow or assessing the status of the newborn after birth The nurse is aware that labor and birth will most likely proceed normally when the fetus is in what position? 1. Right-acromion-dorsal-anterior 2. Right-sacrum-transverse 3. Occiput anterior 4. Posterior position The midwife performs a vaginal exam and determines that the fetal head is at a -2 station. What does this indicate to the nurse about the birth? 1. The birth is imminent. 2. The birth is likely to occur in 1-2 hours. 3. The birth will occur later in the shift. 4. The birth is difficult to predict. Childbirth preparation offers several advantages including which of the following? Select all that apply. 1. It helps a pregnant woman and her support person understand the choices in the birth setting. 2. It promotes awareness of available options. 3. It provides tools for a pregnant woman and her support person to use during labor and birth. 4. Women who receive continuous support during labor require more analgesia, and have more cesarean and instrument births. 5. Each method has been shown to shorten labor. The nurse determines that a client is carrying her fetus in the vertical (longitudinal) lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? Select all that apply. 1. Sacrum 2. Left arm 3. Mentum 4. Left scapula 5. Right scapula The nurse is admitting a client to the birthing unit. What question should the nurse ask to gain a better understanding of the client's psychosocial status? 1. "How did you decide to have your baby at this hospital?" 2. "Who will be your labor support person?" 3. "Have you chosen names for your baby yet?" 4. "What feeding method will you use for your baby?" The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician? 1. Blood pressure 120/88 2. Father a carrier of sickle-cell trait 3. Dark red vaginal bleeding 4. History of domestic abuse The nurse is working with a pregnant adolescent. The client asks the nurse how the baby's condition is determined during labor. The nurse's best response is that during labor, the nurse will do which of the following? 1. Check the client's cervix by doing a pelvic exam every 2 hours. 2. Assess the fetus's heart rate with an electronic fetal monitor. 3. Look at the color and amount of bloody show that the client has. 4. Verify that the client's contractions are strong but not too close together. During the initial intrapartal assessment of a client in early labor, the nurse performs a vaginal examination. The client's partner asks why this pelvic exam needs to be done. The nurse should explain that the purpose of the vaginal exam is to obtain information about which of the following? Select all that apply. 1. Uterine contraction pattern 2. Fetal position 3. Presence of the mucous plug 4. Cervical dilation and effacement 5. Presenting part A client has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus? Select all that apply. 1. Check for ruptured membranes and apply a fetal scalp electrode. 2. Auscultate the fetal heart rate between and during contractions. 3. Palpate contractions and resting uterine tone. 4. Assess the blood pressure, temperature, respiratory rate, and pulse rate. 5. Perform a vaginal exam for cervical dilation, and perform Leopold maneuvers. The nurse is preparing to assess a laboring client who has just arrived in the labor and birth unit. Which statement by the client indicates that additional education is needed? 1. "You are going to do a vaginal exam to see how dilated my cervix is." 2. "The reason for a pelvic exam is to determine how low in the pelvis my baby is." 3. "When you check my cervix, you will find out how thinned out it is." 4. "After you assess my pelvis, you will be able to tell when I will deliver." The client has been pushing for 3 hours, and the fetus is making a slow descent. The partner asks the nurse whether pushing for this long is normal. How should the nurse respond? 1. "Your baby is taking a little longer than average, but is making progress." 2. "First babies take a long time to be born. The next baby will be easier." 3. "The birth would go faster if you had taken prenatal classes and practiced." 4. "Every baby is different; there really are no norms for labor and birth." During a maternal assessment, the nurse determines the fetus to be in a left occiput anterior (LOA) position. Auscultation of the fetal heart rate should begin in what quadrant? 1. Right upper quadrant 2. Left upper quadrant 3. Right lower quadrant 4. Left lower quadrant A laboring client asks the nurse, "Why does the physician want to use an intrauterine pressure catheter (IUPC) during my labor?" The nurse would accurately explain that the best rationale for using an IUPC is which of the following? 1. The IUPC can be used throughout the birth process. 2. A tocodynamometer is invasive. 3. The IUPC provides more accurate data than does the tocodynamometer. 4. The tocodynamometer can be used only after the cervix is dilated 2 cm. The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention? 1. Woman at 7 cm, fetal heart tones auscultated every 90 minutes 2. Woman at 10 cm and pushing, external fetal monitor applied 3. Woman with meconium-stained fluid, internal fetal scalp electrode in use 4. Woman in preterm labor, external monitor in place The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? 1. "The monitor is necessary so we can see how your labor is progressing." 2. "The monitor will prevent complications from the meconium in your fluid." 3. "The monitor helps us to see how the baby is tolerating labor." 4. "The monitor can be removed, and oxygen given instead." The nurse has just palpated contractions and compares the consistency to that of the forehead to estimate the firmness of the fundus. What would the intensity of these contractions be identified as? 1. Mild 2. Moderate 3. Strong 4. Weak Before performing Leopold maneuvers, what would the nurse do? Select all that apply. 1. Have the client empty her bladder. 2. Place the client in Trendelenburg position. 3. Have the client lie on her back with her feet on the bed and knees bent. 4. Turn the client to her left side. 5. Have the client lie flat with her ankles crossed. The student nurse is to perform Leopold maneuvers on a laboring client. Which assessment requires intervention by the staff nurse? 1. The client is assisted into supine position, and the position of the fetus is assessed. 2. The upper portion of the uterus is palpated, then the middle section. 3. After determining where the back is located, the cervix is assessed. 4. Following voiding, the client's abdomen is palpated from top to bottom. The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first? 1. Perform Leopold maneuvers to determine fetal position. 2. Count the fetal heart rate between, during, and for 30 seconds following a uterine contraction (UC). 3. Dry the maternal abdomen before using the Doppler. 4. The diaphragm should be cooled before using the Doppler. After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? 1. Breech presentation 2. Uteroplacental insufficiency 3. Compression of the fetal head 4. Umbilical cord compression The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate? 1. Inform the maternal client that the rate is normal. 2. Reassess the FHR in 5 minutes because the rate is low. 3. Report the FHR to the doctor immediately. 4. Turn the maternal client on her side and administer oxygen. Upon assessing the FHR tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following? Select all that apply. 1. Early fetalhypoxia 2. Prolonged fetal stimulation 3. Fetal anemia 4. Fetal sleep cycle 5. Infection Persistent early decelerations are noted. What would the nurse's first action be? 1. Turn the mother on her left side and give oxygen. 2. Check for prolapsed cord. 3. Do nothing. This is a benign pattern. 4. Prepare for immediate forceps or cesarean delivery. The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best? 1. Document the fetal heart rate. 2. Apply oxygen via mask at 10 liters. 3. Prepare for imminent delivery. 4. Assist the client into Fowler's position. The nurse is caring for a client who is having fetal tachycardia. The nurse knows that possible causes include which of the following? Select all that apply. 1. Maternal dehydration 2. Maternal hyperthyroidism 3. Fetal hypoxia 4. Prematurity 5. Anesthesia or regional analgesia The nurse is teaching a class on reading a fetal monitor to nursing students. The nurse explains that bradycardia is a fetal heart rate baseline below 110 and can be caused by which of the following? Select all that apply. 1. Maternal hypotension 2. Prolonged umbilical cord compression 3. Fetal dysrhythmia 4. Central nervous system malformation 5. Late fetal asphyxia The nurse is caring for a client in the transition phase of labor and notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute. What actions should the nurse take in this situation? Select all that apply. 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous. 5. Reassure the client and her partner that she is doing fine. A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately? 1. Change the client's position in bed. 2. Notify the physician that birth is imminent. 3. Administer oxygen at 2 liters per minute. 4. Begin continuous fetal heart rate monitoring. A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching? 1. "The most important part of fetal heart monitoring is the absence of variable decelerations." 2. "The most important part of fetal heart monitoring is the presence of variability." 3. "The most important part of fetal heart monitoring is the fetal heart rate baseline." 4. "The most important part of fetal heart monitoring is the depth of decelerations." The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? 1. Assist the client to change position. 2. Apply oxygen to the client at 2 liters per nasal cannula. 3. Notify the operating room of the need for a cesarean birth. 4. Determine the color of the leaking amniotic fluid. The nurse is caring for a client who is showing a sinusoidal fetal heart rate pattern on the monitor. The nurse knows that possible causes for this pattern include which of the following? Select all that apply. 1. Fetal anemia 2. Chronic fetal bleeding 3. Maternal hypotension 4. Twin-to-twin transfusion 5. Umbilical cord occlusion Fetal factors that possibly indicate electronic fetal monitoring include which of the following? Select all that apply. 1. Meconium passage 2. Multiple gestation 3. Preeclampsia 4. Grand multiparity 5. Decreased fetal movement The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention? 1. Early decelerations with each contraction 2. Variable decelerations that recover to the baseline 3. Late decelerations with minimal variability 4. Accelerations The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following? 1. Moderate variability 2. Early decelerations 3. Late decelerations 4. Accelerations After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what? 1. Increase the mother's oxygen rate. 2. Turn the mother to the left lateral position. 3. Prepare the mother for a higher-risk delivery. 4. Increase the intravenous infusion rate. The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip? 1. Late decelerations 2. Early decelerations 3. Accelerations 4. Fetal dysrhythmia The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse? 1. "I stimulated the top of the fetus's head to wake him up a little." 2. "I stimulated the top of the fetus's head to try to get his heart rate to accelerate." 3. "I stimulated the top of the fetus's head to calm the fetus down before birth." 4. "I stimulated the top of the fetus's head to find out whether he is in distress." The primary care provider is performing a fetal scalp stimulation test. What result would the nurse hope to observe? Select all that apply. 1. Spontaneous fetal movement 2. Fetal heart acceleration 3. Increase in fetal heart variability 4. Resolution of late decelerations 5. Reactivity associated with the stimulation The laboring client is at 7 cm, with the vertex at a +1 station. Her birth plan indicates that she and her partner took Lamaze prenatal classes, and they have planned on a natural, unmedicated birth. Her contractions are every 3 minutes and last 60 seconds. She has used relaxation and breathing techniques very successfully in her labor until the last 15 minutes. Now, during contractions, she is writhing on the bed and screaming. Her labor partner is rubbing the client's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this client? 1. Fear/Anxiety related to discomfort of labor and unknown labor outcome 2. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent 3. Coping: Family, Compromised, related to labor process 4. Knowledge, Deficient, related to lack of information about normal labor process and comfort measures A client is admitted to the labor and delivery unit with contractions that are regular, are 2 minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8 cm dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of labor? 1. Latent phase 2. Active phase 3. Transition phase 4. Fourth stage Usually, the family is advised to arrive at the birth setting at the beginning of the active phase of labor or when which of the following occur? Select all that apply. 1. Rupture of membranes (ROM) 2. Increased fetal movement 3. Decreased fetal movement 4. Any vaginal bleeding 5. Regular, frequent uterine contractions (UCs) The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Barring any abnormalities, how often would the nurse expect to take the client's temperature? 1. Every hour 2. Every 2 hours 3. Every 4 hours 4. Every shift The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching has been effective? 1. "When a client arrives in labor, a urine specimen is obtained by catheter to check for protein and ketones." 2. "When a client arrives in labor, she will be positioned supine to facilitate a normal blood pressure." 3. "When a client arrives in labor, her prenatal record is reviewed for indications of domestic abuse." 4. "When a client arrives in labor, a vaginal exam is performed unless birth appears to be imminent." The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Indicators of normal labor include which of the following? Select all that apply. 1. Fetal heart rate of 130 with average variability 2. Blood pressure of 130/80 3. Maternal pulse of 160 4. Protein of +1 in urine 5. Odorless, clear fluid on underwear The client is being admitted to the birthing unit. As the nurse begins the assessment, the client's partner asks why the fetus's heart rate will be monitored. After the nurse explains, which statement by the partner indicates a need for further teaching? 1. "The fetus's heart rate will vary between 110 and 160." 2. "The heart rate is monitored to see whether the fetus is tolerating labor." 3. "By listening to the heart, we can tell the gender of the fetus." 4. "After listening to the heart rate, you will contact the midwife." The nurse has completed the physical assessment of a client in early labor, and proceeds with the social assessment. A social history of the client would include which of the following? Select all that apply. 1. Use of drugs and alcohol 2. Family violence or sexual assault 3. Current living situation 4. Type of insurance 5. Availability of resources A first-time 22-year-old single labor client, accompanied by her boyfriend, is admitted to the labor unit with ruptured membranes and mild to moderate contractions. She is determined to be 2 centimeters dilated. Which nursing diagnoses might apply during the current stage of labor? Select all that apply. 1. Fear/Anxiety related to discomfort of labor and unknown labor outcome 2. Knowledge, Deficient, related to lack of information about pushing methods 3. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent 4. Pain, Acute, related to perineal trauma 5. Coping: Family, Compromised, related to labor process The laboring client and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first? 1. The sterile vaginal exam 2. Welcoming the couple 3. Auscultation of the fetal heart rate 4. Checking for ruptured membranes An expectant father has been at the bedside of his laboring partner for more than 12 hours. An appropriate nursing intervention would be to do which of the following? 1. Insist that he leave the room for at least the next hour. 2. Tell him he is not being as effective as he was, and that he needs to let someone else take over. 3. Offer to remain with his partner while he takes a break. 4. Suggest that the client's mother might be of more help. By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily doing which of the following? 1. Recognizing the client as an active participant in her own care. 2. Attempting to correct any misinformation the client might have received. 3. Acting as an advocate for the client. 4. Establishing rapport with the client. The labor and birth nurse is admitting a client. The nurse's assessment includes asking the client whom she would like to have present for the labor and birth, and what the client would prefer to wear. The client's partner asks the nurse the reason for these questions. What would the nurse's best response be? Select all that apply 1. "These questions are asked of all women. It's no big deal." 2. "I'd prefer that your partner ask me all the questions, not you." 3. "A client's preferences for her birth are important for me to understand." 4. "Many women have beliefs about childbearing that affect these choices." 5. "I'm gathering information that the nurses will use after the birth." The laboring client presses the call light and reports that her water has just broken. What would the nurse's first action be? 1. Check fetal heart tones. 2. Encourage the mother to go for a walk. 3. Change bed linens. 4. Call the physician. The laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? 1. Encourage the husband to remain in the room. 2. Keep the client on bed rest at this time. 3. Apply an internal fetal scalp electrode. 4. Obtain a clean-catch urine specimen. The client has stated that she wants to avoid an epidural and would like an unmedicated birth. Which nursing action is most important for this client? 1. Encourage the client to vocalize during contractions. 2. Perform vaginal exams only between contractions. 3. Provide a CD of soft music with sounds of nature. 4. Offer to teach the partner how to massage tense muscles. The nurse is aware of the different breathing techniques that are used during labor. Why are breathing techniques used during labor? Select all that apply. 1. They are a form of anesthesia. 2. They are a source of relaxation. 3. They increase the ability to cope with contractions. 4. They are a source of distraction. 5. They increase a woman's pain threshold. Two hours after delivery, a client's fundus is boggy and has risen to above the umbilicus. What is the first action the nurse would take? 1. Massage the fundus until firm 2. Express retained clots 3. Increase the intravenous solution 4. Call the physician Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void frequently? 1. A full bladder impedes oxygen flow to the fetus. 2. Frequent voiding prevents bruising of the bladder. 3. Frequent voiding encourages sphincter control. 4. A full bladder can impede fetal descent. The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of the following? 1. Hyperventilation 2. Seizure auras 3. Imminent birth 4. Anxiety A client who wishes to have an unmedicated birth is in the transition stage. She is very uncomfortable and turns frequently in the bed. Her partner has stepped out momentarily. How can the nurse be most helpful? 1. Talk to the client the entire time. 2. Turn on the television to distract the client. 3. Stand next to the bed with hands on the railing next to the client. 4. Sit silently in the room away from the bed. A full-term infant has just been born. Which interventions should the nurse perform first? Select all that apply. 1. Placing the infant in a radiant-heated unit 2. Suctioning the infant with a bulb syringe 3. Wrapping the infant in a blanket 4. Evaluating the newborn using the Apgar system 5. Offering a feeding of 5% glucose water The nurse administered oxytocin 20 units at the time of placental delivery. Why was this primarily done? 1. To contract the uterus and minimize bleeding 2. To decrease breast milk production 3. To decrease maternal blood pressure 4. To increase maternal blood pressure A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention? 1. A soaked perineal pad since the last 15-minute check 2. An edematous perineum 3. The client experiencing tremors 4. A fundus located at the umbilicus The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are flexed, and resist straightening. What should the nurse record as this infant's Apgar score? 1. 7 2. 8 3. 9 4. 10 Before applying a cord clamp, the nurse assesses the umbilical cord. The mother asks why the nurse is doing this. What should the nurse reply? 1. "I'm checking the blood vessels in the cord to see whether it has one artery and one vein." 2. "I'm checking the blood vessels in the cord to see whether it has two arteries and one vein." 3. "I'm checking the blood vessels in the cord to see whether it has two veins and one artery." 4. "I'm checking the blood vessels in the cord to see whether it has two arteries and two veins." At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this infant's Apgar score? 1. 7 2. 8 3. 9 4. 10 Upon delivery of the newborn, what nursing intervention most promotes parental attachment? 1. Placing the newborn under the radiant warmer. 2. Placing the newborn on the mother's abdomen. 3. Allowing the mother a chance to rest immediately after delivery. 4. Taking the newborn to the nursery for the initial assessment. A young adolescent is transferred to the labor and delivery unit from the emergency department. The client is in active labor, but did not know she was pregnant. What is the most important nursing action? 1. Determine who might be the father of the baby for paternity testing. 2. Ask the client what kind of birthing experience she would like to have. 3. Assess blood pressure and check for proteinuria. 4. Obtain a Social Services referral to discuss adoption. As compared with admission considerations for an adult woman in labor, the nurse's priority for an adolescent in labor would be which of the following? 1. Cultural background 2. Plans for keeping the infant 3. Support persons 4. Developmental level When caring for a 13-year-old client in labor, how would the nurse provide sensitive care? Select all that apply. 1. Using simple and concrete instructions 2. Providing soothing encouragement and comfort measures 3. Making all decisions for the client when she expresses a feeling of helplessness 4. Deciding whom the client should allow in the room 5. Providing encouragement and support of the client's decisions An abbreviated systematic physical assessment of the newborn is performed by the nurse in the birthing area to detect any abnormalities. Normal findings would include which of the following? Select all that apply. 1. Skin color: Body blue with pinkish extremities 2. Umbilical cord: two veins and one artery 3. Respiration rate of 30-60 irregular 4. Temperature of above 36.5°C (97.8°F) 5. Sole creases that involve the heel A client's labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse do? 1. Go to the nurse's station and immediately call the physician. 2. Run to the delivery room for an emergency birth pack. 3. Stay with the client and ask auxiliary personnel for assistance. 4. Hold back the infant's head forcibly until the physician arrives for the delivery. Which of the following is a common barbiturate used in labor? 1. Seconal 2. Valium 3. Phenergan 4. Vistaril The nurse is assessing a client before administering an analgesic. What are some of the factors the nurse should consider? Select all that apply. 1. The client is willing to receive medication after being advised about it. 2. The client's vital signs are stable. 3. The partner agrees to use of the medication. 4. The client has no known allergies to the medication. 5. The client is aware of the contraindications of the medication. A client in labor is requesting pain medication. The nurse assesses her labor status first, focusing on which of the following? Select all that apply. 1. Contraction pattern 2. Amount of cervical dilatation 3. When the labor began 4. Whether the membranes are intact or ruptured 5. Fetal presenting part A woman in active labor is given nalbuphine hydrochloride (Nubain) 14 mg IV for pain relief. Half an hour later, her respirations are at 8 per minute. The physician would likely order which medication for this client? 1. Narcan 2. Reglan 3. Benadryl 4. Vistaril An analgesic medication has been administered intramuscularly to a client in labor. How would the nurse evaluate if the medication was effective? 1. The client dozes between contractions. 2. The client is moaning during contractions. 3. The contractions decrease in intensity. 4. The contractions decrease in frequency. A client is having contractions that last 20-30 seconds and that are occurring every 8-20 minutes. The client is requesting something to help relieve the discomfort of contractions. What should the nurse suggest? 1. That a mild analgesic be administered 2. An epidural 3. A local anesthetic block 4. Nonpharmacologic methods of pain relief Two hours after an epidural infusion has begun, a client complains of itching on her face and neck. What should the nurse do? 1. Remove the epidural catheter and apply a Band-Aid to the injection site. 2. Offer the client a cool cloth and let her know the itching is temporary. 3. Recognize that this is a common side effect, and follow protocol for administration of Benadryl. 4. Call the anesthesia care provider to re-dose the epidural catheter. A client has just been admitted for labor and delivery. She is having mild contractions lasting 30 seconds every 15 minutes. The client wants to have a medication-free birth. When discussing medication alternatives, the nurse should be sure the client understands which of the following? 1. In order to respect her wishes, no medication will be given. 2. Pain relief will allow a more enjoyable birth experience. 3. The use of medications allows the client to rest and be less fatigued. 4. Maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia. A nurse is checking the postpartum orders. The doctor has prescribed bed rest for 6-12 hours. The nurse knows this is an appropriate order if the client had which type of anesthesia? 1. Spinal 2. Pudendal 3. General 4. Epidural Toward the end of the first stage of labor, a pudendal block is administered transvaginally. What will the nurse anticipate the client's care will include? 1. Monitoring for hypotension every 15 minutes 2. Monitoring FHR every 15 minutes 3. Monitoring for bladder distention 4. No additional assessments Narcotic analgesia is administered to a laboring client at 10:00 a.m. The infant is delivered at 12:30 p.m. What would the nurse anticipate that the narcotic analgesia could do? 1. Be used in place of preoperative sedation 2. Result in neonatal respiratory depression 3. Prevent the need for anesthesia with an episiotomy 4. Enhance uterine contractions After nalbuphine hydrochloride (Nubain) is administered, labor progresses rapidly, and the baby is born less than 1 hour later. The baby shows signs of respiratory depression. Which medication should the nurse be prepared to administer to the newborn? 1. Fentanyl (Sublimaze) 2. Butorphanol tartrate (Stadol) 3. Naloxone (Narcan) 4. Pentobarbital (Nembutal) The nurse has presented a session on pain relief options to a prenatal class. Which statement indicates that additional teaching is needed? 1. "An epidural can be continuous or can be given in one dose." 2. "A spinal is usually used for a cesarean birth." 3. "Pudendal blocks are effective when a vacuum is needed." 4. "Local anesthetics provide good labor pain relief." What is the major adverse side effect of epidural anesthesia? 1. Maternal hypotension 2. Decrease in variability of the FHR 3. Vertigo 4. Decreased or absent respiratory movements Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring client in which position? 1. On her right side in the center of the bed with her back curved 2. Lying prone with a pillow under her chest 3. On her left side with the bottom leg straight and the top leg slightly flexed 4. Sitting on the edge of the bed The laboring client brought a written birth plan indicating that she wanted to avoid pain medications and an epidural. She is now at 6 cm and states, "I can't stand this anymore! I need something for pain! How will an epidural affect my baby?" What is the nurse's best response? 1. "The narcotic in the epidural will make both you and the baby sleepy." 2. "It is unlikely that an epidural will decrease your baby's heart rate." 3. "Epidurals tend to cause low blood pressure in babies after birth." 4. "I can't get you an epidural, because of your birth plan." After administration of an epidural anesthetic to a client in active labor, it is most important to assess the mother immediately for which of the following? 1. Hypotension 2. Headache 3. Urinary retention 4. Bradycardia A laboring client has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, what would the nurse expect to do? 1. Observe fetal heart rate variability 2. Hydrate the vascular system with 500-1000 mL of intravenous fluids 3. Place the client in the semi-Fowler's position 4. Teach the client appropriate breathing techniques The nurse knows that which of the following are advantages of spinal block? Select all that apply. 1. Intense blockade of sympathetic fibers 2. Relative ease of administration 3. Maternal compartmentalization of the drug 4. Immediate onset of anesthesia 5. Larger drug volume A client had an epidural inserted 2 hours ago. It is functioning well, the client is stable, and labor is progressing. Which parts of the nurse's assessment have the highest priority? Select all that apply. 1. Assess blood pressure every hour. 2. Assess the pulse rate every hour. 3. Palpate the bladder. 4. Auscultate the lungs. 5. Assess the reflexes. For what common side effects of epidural anesthesia should the nurse watch? Select all that apply. 1. Elevated maternal temperature 2. Urinary retention 3. Nausea 4. Long-term back pain 5. Local itching A client dilated to 5 cm has just received an epidural for pain. She complains of feeling lightheaded and dizzy within 10 minutes after the procedure. Her blood pressure was 120/80 before the procedure and is now 80/52. In addition to the bolus of fluids she has been given, which medication is preferred to increase her BP? 1. Epinephrine 2. Terbutaline 3. Ephedrine 4. Epifoam A client received epidural anesthesia during the first stage of labor. The epidural is discontinued immediately after delivery. This client is at increased risk for which problem during the fourth stage of labor? 1. Nausea 2. Bladder distention 3. Uterine atony 4. Hypertension When general anesthesia is necessary for a cesarean delivery, what should the nurse be prepared to do? Select all that apply. 1. Administer an antacid to the client. 2. Place a wedge under her thigh. 3. Apply cricoid pressure during anesthesia intubation. 4. Preoxygenate for 3-5 minutes before anesthesia. 5. Place a Foley catheter in the client's bladder. The client at 39 weeks' gestation is undergoing a cesarean birth due to breech presentation. General anesthesia is being used. Which situation requires immediate intervention? 1. The baby's hands and feet are blue at 1 minute after birth. 2. The fetal heart rate is 70 prior to making the skin incision. 3. Clear fluid is obtained from the baby's oropharynx. 4. The neonate cries prior to delivery of the body. The nurse is providing preoperative teaching to a client for whom a cesarean birth under general anesthesia is scheduled for the next day. Which statement by the client indicates that she requires additional information? 1. "General anesthesia can be accomplished with inhaled gases." 2. "General anesthesia usually involves administering medication into my IV." 3. "General anesthesia will provide good pain relief after the birth." 4. "General anesthesia takes effect faster than an epidural A cesarean section is ordered for a pregnant client. Because the client is to receive general anesthesia, what is the primary danger with which the nurse is concerned? 1. Fetal depression 2. Vomiting 3. Maternal depression 4. Uterine relaxation A cesarean section is ordered for the laboring client with whom the nurse has worked all shift. The client will receive general anesthesia. The nurse knows that potential complications of general anesthesia include which of the following? Select all that apply. 1. Fetal depression that is directly proportional to the depth and duration of the anesthesia 2. Poor fetal metabolism of anesthesia, which inhibits use with preterm infants 3. Uterine relaxation 4. Increased gastric motility 5. Itching of the face and neck The client with a normal pregnancy had an emergency cesarean birth under general anesthesia 2 hours ago. The client now has a respiratory rate of 30, pale blue nail beds, a pulse rate of 110, and a temperature of 102.6°F, and is complaining of chest pain. The nurse understands that the client most likely is experiencing which of the following? 1. Pulmonary embolus 2. Pneumococcal pneumonia 3. Pneumonitis 4. Gastroesophageal reflux disease The nurse is inducing the labor of a client with severe preeclampsia. As labor progresses, fetal intolerance of labor develops. The induction medication is turned off, and the client is prepared for cesarean birth. Which statement should the nurse include in her preoperative teaching? 1. "Because of your preeclampsia you are at higher risk for hypotension after an epidural anesthesia." 2. "Because of your preeclampsia you might develop hypertension after a spinal anesthesia." 3. "Because of your preeclampsia your baby might have decreased blood pressure after birth." 4. "Because of your preeclampsia An anesthesiologist informs the nurse that a client scheduled for a caesarean section will be having general anesthesia with postoperative self-controlled analgesia. For which clients would a general anesthesia be recommended? Select all that apply. 1. The client with a history of hypertension 2. The client who has had a lower back fusion 3. The client who is 13 years old 4. The client who is allergic to morphine sulfate 5. The client who has had surgery for scoliosis To reduce possible side effects from a cesarean section under general anesthesia, clients are routinely given which type of medication? 1. Antacids 2. Tranquilizers 3. Antihypertensives 4. Anticonvulsants The nurse is caring for a laboring client with thrombocytopenia. During labor, it is determined that the client requires a cesarean delivery. The nurse is preparing the client for surgery, and should instruct the client that the recommended method of anesthesia is which of the following? 1. General anesthesia 2. Epidural anesthesia 3. Spinal anesthesia 4. Regional anesthesia Which of the following is a major side effect of butorphanol tartrate (Stadol)? 1. Blurred vision 2. Agitation 3. Feelings of dysphoria 4. Drowsiness The primary physician orders a narcotic analgesic for a client in labor. Which situations would lead the nurse to hold the medication? Select all that apply. 1. Contraction pattern every 3 minutes for 60 seconds 2. Fetal monitor tracing showing late decelerations 3. Client sleeping between contractions 4. Blood pressure 150/90 5. Blood pressure 80/42 The nurse has admitted a woman with cervical insufficiency. The nurse is aware that causes of this condition include which of the following? Select all that apply. 1. Congenital factors 2. Intercourse during pregnancy 3. Infection 4. Increased uterine volume 5. Past cervical surgeries The nurse is admitting a client for a cerclage procedure. The client asks for information about the procedure. What is the nurse's most accurate response? 1. "A stitch is placed in the cervix to prevent a spontaneous abortion or premature birth." 2. "The procedure is done during the third trimester." 3. "Cerclage is always placed after the cervix has dilated and effaced." 4. "An uncomplicated elective cerclage may is done on inpatient basis." A client is admitted to the labor and delivery unit with a history of ruptured membranes for 2 hours. This is her sixth delivery; she is 40 years old, and smells of alcohol and cigarettes. What is this client at risk for? 1. Gestational diabetes 2. Placenta previa 3. Abruptio placentae 4. Placenta accrete The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching? 1. "If I were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured." 2. "If I develop a urinary tract infection in my next pregnancy, I might rupture membranes early again." 3. "If I want to become pregnant again, I will have to plan on being on bed rest for the whole pregnancy." 4. "If I have aminocentesis, I might rupture the membranes again." A client was admitted to the labor area at 5 cm with ruptured membranes about 14 hours ago. What assessment data would be most beneficial for the nurse to collect? 1. Blood pressure 2. Temperature 3. Pulse 4. Respiration The nurse admits into the labor area a client who is in preterm labor. What assessment finding would constitute a diagnosis of preterm labor? 1. Cervical effacement of 30% or more 2. Cervical change of 0.5 cm per hour 3. 2 contractions in 30 minutes 4. 8 contractions in 1 hour During the nursing assessment of a woman with ruptured membranes, the nurse suspects a prolapsed umbilical cord. What would the nurse's priority action be? 1. To help the fetal head descend faster 2. To use gravity and manipulation to relieve compression on the cord 3. To facilitate dilation of the cervix with prostaglandin gel 4. To prevent head compression A client is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes, and FHR of 150 bpm. Her membranes rupture spontaneously, and the FHR drops to 90 bpm with variable decelerations. What would the nurse's initial response be? 1. Perform a vaginal exam 2. Notify the physician 3. Place the client in a left lateral position 4. Administer oxygen at 2 L per nasal cannula The nurse has received end-of-shift reports in the high-risk maternity unit. Which client should the nurse see first? 1. The client at 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement 2. The client at 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations 3. The client at 35 weeks' gestation with grade I abruptio placentae in labor who has a strong urge to push 4. The client at 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously The nurse is presenting a class on preterm labor, its causes, and treatments to a group of newly pregnant couples. Which statements regarding preterm labor are true? Select all that apply. 1. Antepartum hemorrhage can cause preterm labor. 2. Trauma can cause preterm labor. 3. Infection can cause preterm labor. 4. Magnesium sulfate is a drug used to stop contractions. 5. Sedatives and narcotics may be given to stop labor. A client in her second trimester is complaining of spotting. Causes for spotting in the second trimester are diagnosed primarily through the use of which of the following? 1. A nonstress test 2. A vibroacoustic stimulation test 3. An ultrasound 4. A contraction stress test A client at 32 weeks' gestation is admitted with painless vaginal bleeding. Placenta previa has been confirmed by ultrasound. What should be included in the nursing plan? Select all that apply. 1. No vaginal exams 2. Encouraging activity 3. No intravenous access until labor begins 4. Evaluating fetal heart rate with an external monitor 5. Monitoring blood loss, pain, and uterine contractility The nurse is planning an in-service educational program to talk about disseminated intravascular coagulation (DIC). The nurse should identify which conditions as risk factors for developing DIC? Select all that apply. 1. Diabetes mellitus 2. Abruptio placentae 3. Fetal demise 4. Multiparity 5. Preterm labor The client at 30 weeks' gestation is admitted with painless late vaginal bleeding. The nurse understands that expectant management includes which of the following? 1. Limiting vaginal exams to only one per 24-hour period. 2. Evaluating the fetal heart rate with an internal monitor. 3. Monitoring for blood loss, pain, and uterine contractibility. 4. Assessing blood pressure every 2 hours. A client is admitted to the labor and delivery unit in active labor. What nursing diagnoses might apply to the client with suspected abruptio placentae? Select all that apply. 1. Fluid Volume, Deficient, Risk for, related to hypovolemia secondary to excessive blood loss 2. Tissue Perfusion: Peripheral, Ineffective, related to blood loss secondary to uterine atony following birth 3. Anxiety related to concern for own personal status and the baby's safety 4. Knowledge, Deficient related to lack of information about inherited genetic defects 5. Alteration in Respiratory Function related to blood loss What is the most significant cause of neonatal morbidity and mortality? 1. Amenorrhea 2. Posttraumatic stress disorder 3. Prematurity 4. Endometriosis What is the most significant maternal risk factor for preterm birth? 1. Previous preterm birth 2. Smoking 3. Stress 4. Substance abuse A pregnant client is admitted to the emergency department with bleeding. The nurse realizes that the client might have placenta previa. Which signs would be suggestive of placenta previa? 1. Bright red vaginal bleeding 2. Sudden onset of vaginal bleeding 3. Firm and hard uterus 4. Change in the size of abdomen The nurse educator is describing the different kinds of abruptio placentae to a group of students, explaining that in a complete abruptio placentae, which of the following occurs? 1. Separation begins at the periphery of the placenta. 2. The placenta separates centrally and blood is trapped between the placenta and the uterine wall. 3. There is massive vaginal bleeding in the presence of almost total separation. 4. Blood passes between the fetal membranes and the uterine wall, and escapes vaginally. The labor nurse is caring for a client at 38 weeks' gestation who has been diagnosed with symptomatic placenta previa. Which physician order should the nurse question? 1. Begin oxytocin drip rate at 0.5 milliunits/min. 2. Assess fetal heart rate every 10 minutes. 3. Weigh all vaginal pads. 4. Assess hematocrit and hemoglobin. The nurse is presenting a class for nursing students on multiple-gestation pregnancy. Which statements about multiple-gestation pregnancies are accurate? Select all that apply. 1. Hypertension is a major maternal complication. 2. Gestational diabetes occurs more often. 3. Maternal anemia occurs. 4. Pulmonary embolism is 12 times more likely to develop during pregnancy with multiple gestations. 5. Multiple gestations are more likely to acquire HELLP. What can be determined based on ultrasound visualization or the lack of visualization of an intertwin membrane? 1. Toxicity 2. Amnionicity 3. Variability 4. Prematurity What fetal factors require a cesarean birth? 1. Severe intrauterine growth restriction (IUGR) 2. Fetal anomalies 3. Unfavorable fetal position or presentation 4. Preterm birth 5. Lack of maternal attachment The home health nurse is admitting a client at 18 weeks who is pregnant with twins. Which nursing action is most important? 1. Teach the client about foods that are good sources of protein. 2. Assess the client's blood pressure in her upper right arm. 3. Determine whether the pregnancy is the result of infertility treatment. 4. Collect a cervicovaginal fetal fibronectin (fFN) specimen. The client is carrying monochorionic-monoamniotic twins. The nurse teaches the client what this is, and the implications of this finding. The nurse knows that teaching is successful when the client states which of the following? 1. "My babies came from two eggs." 2. "About two thirds of twins have this amniotic sac formation." 3. "My use of a fertility drug led to this issue." 4. "My babies have a lower chance of surviving to term than fraternal twins do." When counseling a newly pregnant client at 8 weeks' gestation of twins, the nurse teaches the woman about the need for increased caloric intake. What would the nurse tell the woman that the minimum recommended intake should be? 1. 2500 kcal and 120 grams protein 2. 3000 kcal and 150 grams protein 3. 4000 kcal and 135 grams protein 4. 5000 kcal and 190 grams protein Intervention to reduce preterm birth can be divided into primary prevention and secondary prevention. What does secondary prevention include? 1. Diagnosis and treatment of infections 2. Cervical cerclage 3. Progesterone administration 4. Antibiotic treatment and tocolysis The nurse is caring for a client with hydramnios. What will the nurse watch for? 1. Possible intrauterine growth restriction 2. Newborn congenital anomalies 3. Newborn postmaturity and renal malformations 4. Fetal adhesions Slowly removing some amniotic fluid is a treatment for hydramnios. What consequence can occur with the withdrawal of fluid? 1. Preterm labor 2. Prolapsed cord 3. Preeclampsia 4. Placenta previa The nurse is admitting a client who was diagnosed with hydramnios. The client asks why she has developed this condition. The nurse should explain that hydramnios is sometimes associated with which of the following? Select all that apply. 1. Rh sensitization 2. Postmaturity syndrome 3. Renal malformation or dysfunction 4. Maternal diabetes 5. Large-for-gestational-age infants The nurse is admitting a client with possible hydramnios. When is hydramnios most likely suspected? 1. Hydramnios is most likely suspected when there is less amniotic fluid than normal for gestation. 2. Hydramnios is most likely suspected when the fundal height increases disproportionately to the gestation. 3. Hydramnios is most likely suspected when the woman has a twin gestation. 4. Hydramnios is most likely suspected when the quadruple screen comes back positive. If oligohydramnios occurs in the first part of pregnancy, the nurse knows that there is a danger of which of the following? 1. Major congenital anomalies 2. Fetal adhesions 3. Maternal diabetes 4. Rh sensitization When caring for a laboring client with oligohydramnios, what should the nurse be aware of? Select all that apply. 1. Increased risk of cord compression 2. Decreased variability 3. Labor progress is often more rapid than average 4. Presence of periodic decelerations 5. During gestation, fetal skin and skeletal abnormalities can occur The nurse knows that a baby born to a mother who had oligohydramnios could show signs of which of the following? 1. Respiratory difficulty 2. Hypertension 3. Heart murmur 4. Decreased temperature The client at 38 weeks' gestation has been diagnosed with oligohydramnios. Which statement indicates that teaching about the condition has been effective? 1. "My gestational diabetes might have caused this problem to develop." 2. "When I go into labor, I should come to the hospital right away." 3. "This problem was diagnosed with blood and urine tests." 4. "Women with this condition usually do not have a cesarean birth." The nurse is planning care for a client with hydramnios. For which interventions might the nurse need to prepare the client? Select all that apply. 1. Artificial rupture of the membranes 2. Amnioinfusion 3. Amniocentesis 4. Administration of prostaglandin synthesis inhibitor 5. Administration of indomethacin What would be a normal cervical dilatation rate in a first-time mother ("primip")? 1. 1.5 cm per hour 2. Less than 1 cm cervical dilatation per hour 3. 1 cm per hour 4. Less than 0.5 cm per hour Dystocia encompasses many problems in labor. What is the most common? 1. Meconium-stained amniotic fluid 2. Dysfunctional uterine contractions 3. Cessation of contractions 4. Changes in the fetal heart rate Risk factors for tachysystole include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cocaine use 2. Placental abruption 3. Low-dose oxytocin titration regimens 4. Uterine rupture 5. Smoking A woman has been having contractions since 4 a.m. At 8 a.m., her cervix is dilated to 5 cm. Contractions are frequent, and mild to moderate in intensity. Cephalopelvic disproportion (CPD) has been ruled out. After giving the mother some sedation so she can rest, what would the nurse anticipate preparing for? 1. Oxytocin induction of labor 2. Amnioinfusion 3. Increased intravenous infusion 4. Cesarean section Nonreassuring fetal status often occurs with a tachysystole contraction pattern. Intrauterine resuscitation measures may become warranted and can include which of the following measures? Select all that apply. 1. Position the woman on her right side. 2. Apply oxygen via face mask. 3. Call for anesthesia provider for support. 4. Increase intravenous fluids by at least 700 mL bolus. 5. Call the physician/CNM to the bedside. The nurse is making client assignments for the next shift. Which client is most likely to experience a complicated labor pattern? 1. 34-year-old woman at 39 weeks' gestation with a large-for-gestational-age (LGA) fetus 2. 22-year-old woman at 23 weeks' gestation with ruptured membranes 3. 30-year-old woman at 41 weeks' gestation and estimated fetal weight 7 pounds 8 ounces 4. 43-year-old woman at 37 weeks' gestation with hypertension Two hours ago, a client at 39 weeks' gestation was 3 cm dilated, 40% effaced, and +1 station. Frequency of contractions was every 5 minutes with duration 40 seconds and intensity 50 mmHg. The current assessment is 4 cm dilated, 40% effaced, and +1 station. Frequency of contractions is now every 3 minutes with 40-50 seconds' duration and intensity of 40 mmHg. What would the priority intervention be? 1. Begin oxytocin after assessing for CPD. 2. Give terbutaline to stop the preterm labor. 3. Start oxygen at 8 L/min. 4. Have the anesthesiologist give the client an epidural. What are the primary complications of placenta accrete? Select all that apply. 1. Maternal hemorrhage 2. Insomnia 3. Failure of the placenta to separate following birth of the infant 4. Autonomic dysreflexia 5. Shoulder dystocia Risk factors for labor dystocia include which of the following? Select all that apply. 1. Tall maternal height 2. Labor induction 3. Small-for-gestational-age (SGA) fetus 4. Malpresentation 5. Prolonged latent phase In succenturiate placenta, one or more accessory lobes of fetal villi have developed on the placenta, with vascular connections of fetal origin. What is the gravest maternal danger? 1. Cord prolapse 2. Postpartum hemorrhage 3. Paroxysmal hypertension 4. Brachial plexus injury The nurse knows that the maternal risks associated with postterm pregnancy include which of the following? Select all that apply. 1. Polyhydramnios 2. Maternal hemorrhage 3. Maternal anxiety 4. Forceps-assisted delivery 5. Perineal damage The client is at 42 weeks' gestation. Which order should the nurse question? 1. Obtain biophysical profile today. 2. Begin nonstress test now. 3. Schedule labor induction for tomorrow. 4. Have the client return to the clinic in 1 week. During labor, the fetus was in a brow presentation, but after a prolonged labor, the fetus converted to face presentation and was delivered vaginally with forceps assist. What should the nurse explain to the parents? 1. The infant will need to be observed for meconium aspiration. 2. Facial edema and head molding will subside in a few days. 3. The infant will be given prophylactic antibiotics. 4. Breastfeeding will need to be delayed for a day or two. The multiparous client at term has arrived to the labor and delivery unit in active labor with intact membranes. Leopold maneuvers indicate the fetus is in a transverse lie with a shoulder presentation. Which physician order is most important? 1. Artificially rupture membranes. 2. Apply internal fetal scalp electrode. 3. Monitor maternal blood pressure every 15 minutes. 4. Alert surgical team of urgent cesarean. The nurse should anticipate the labor pattern for a fetal occiput posterior position to be which of the following? 1. Shorter than average during the latent phase 2. Prolonged as regards the overall length of labor 3. Rapid during transition 4. Precipitous Maternal risks of occiput posterior (OP) malposition include which of the following? Select all that apply. 1. Blood loss greater than 1000 mL 2. Postpartum infection 3. Anal sphincter injury 4. Higher rates of vaginal birth 5. Instrument delivery Which of the following potential problems would the nurse consider when planning care for a client with a persistent occiput posterior position of the fetus? Select all that apply. 1. Increased fetal mortality 2. Severe perineal lacerations 3. Ceasing of labor progress 4. Fetus born in posterior position 5. Intense back pain during labor If the physician indicates a shoulder dystocia during the delivery of a macrosomic fetus, how would the nurse assist? 1. Call a second physician to assist. 2. Prepare for an immediate cesarean delivery. 3. Assist the woman into McRoberts maneuver. 4. Utilize fundal pressure to push the fetus out. The client has undergone an ultrasound, which estimated fetal weight at 4500 g (9 pounds 14 ounces). Which statement indicates that additional teaching is needed? 1. "Because my baby is big, I am at risk for excessive bleeding after delivery." 2. "Because my baby is big, his blood sugars could be high after he is born." 3. "Because my baby is big, my perineum could experience trauma during the birth." 4. "Because my baby is big, his shoulders could get stuck and a collarbone broken." The client vaginally delivers an infant that weighs 4750 g. Moderate shoulder dystocia occurred during the birth. During the initial assessment of this infant, what should the nurse look for? 1. Bell's palsy 2. Bradycardia 3. Erb palsy 4. Petechiae The nurse caring for a client in labor anticipates fetal macrosomia and shoulder dystocia. Appropriate management of shoulder dystocia is essential in order to prevent which fetal complications? Select all that apply. 1. Brachial plexus injury 2. Fractured clavicle 3. Asphyxia 4. Neurological damage 5. Puerperal infection True postterm pregnancies are frequently associated with placental changes that cause a decrease in the uterine-placental-fetal circulation. Complications related to alternations in placenta functioning include which of the following? Select all that apply. 1. Increased fetal oxygenation 2. Increased placental blood supply 3. Reduced nutritional supply 4. Macrosomia 5. Risk of shoulder dystocia The nurse examines the client's placenta and finds that the umbilical cord is inserted at the placental margin. The client comments that the placenta and cord look different than they did for her first two births. The nurse should explain that this variation in placenta and cord is called what? 1. Placenta accreta 2. Circumvallate placenta 3. Succenturiate placenta 4. Battledore placenta A woman is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes and FHR of 150 beats/min. Her membranes rupture spontaneously, and the FHR drops to 90 beats/min with variable decelerations. What would the initial response from the nurse be? 1. Perform a vaginal exam. 2. Notify the physician. 3. Place the client in a left lateral position. 4. Administer oxygen at 2 L per nasal cannula. The nurse is caring for a client in active labor. The membranes spontaneously rupture, with a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time? 1. Assess the odor of the amniotic fluid. 2. Perform Leopold maneuvers. 3. Obtain an order for pain medication. 4. Complete a sterile vaginal exam. During labor, the client at 4 cm suddenly becomes short of breath, cyanotic, and hypoxic. The nurse must prepare or arrange immediately for which of the following? Select all that apply. 1. Intravenous access 2. Cesarean delivery 3. Immediate vaginal delivery 4. McRoberts maneuver 5. A crash cart On assessment, a labor client is noted to have cardiovascular and respiratory collapse and is unresponsive. What should the nurse suspect? 1. An amniotic fluid embolus 2. Placental abruption 3. Placenta accreta 4. Retained placenta Five clients are in active labor in the labor unit. Which women should the nurse monitor carefully for the potential of uterine rupture? Select all that apply. 1. Age 15, in active labor 2. Age 22, with eclampsia 3. Age 25, last delivery by cesarean section 4. Age 32, first baby died during labor 5. Age 27, last delivery 11 months ago The nurse is caring for a client who could be at risk for uterine rupture. The nurse is monitoring the fetus closely for which of the following? Select all that apply. 1. Late decelerations 2. Bradycardia 3. Loss of ability to determine fetal station 4. Tachycardia 5. Early decelerations A 26-year-old client is having her initial prenatal appointment. The client reports to the nurse that she suffered a pelvic fracture in a car accident 3 years ago. The client asks whether her pelvic fracture might affect her ability to have a vaginal delivery. What response by the nurse is best? 1. "It depends on how your pelvis healed." 2. "You will need to have a cesarean birth." 3. "Please talk to your doctor about that." 4. "You will be able to delivery vaginally." In caring for a client with a uterine rupture, the nurse determines which nursing diagnoses to be appropriate? Select all that apply. 1. Gas Exchange, Impaired 2. Fear related to unknown outcome 3. Coping, Ineffective 4. Mobility: Physical, Impaired 5. Anxiety A fetal weight is estimated at 4490 grams in a client at 38 weeks' gestation. Counseling should occur before labor regarding which of the following? 1. Mother's undiagnosed diabetes 2. Likelihood of a cesarean delivery 3. Effectiveness of epidural anesthesia with a large fetus 4. Need for early delivery A woman has been in labor for 16 hours. Her cervix is dilated to 3 cm and is 80% effaced. The fetal presenting part is not engaged. The nurse would suspect which of the following? 1. Breech malpresentation 2. Fetal demise 3. Cephalopelvic disproportion (CPD) 4. Abruptio placentae What is one of the most common initial signs of nonreassuring fetal status? 1. Meconium-stained amniotic fluid 2. Cyanosis 3. Dehydration 4. Arrest of descent The client gave birth to a 7 pound, 14 ounce female 30 minutes ago. The placenta has not yet delivered. Manual removal of the placenta is planned. What should the nurse prepare to do? 1. Start an IV of lactated Ringer's. 2. Apply anti-embolism stockings. 3. Bottle-feed the infant. 4. Send the placenta to pathology. The client delivered 30 minutes ago. Her blood pressure and pulse are stable. Vaginal bleeding is scant. The nurse should prepare for which procedure? 1. Abdominal hysterectomy 2. Manual removal of the placenta 3. Repair of perineal lacerations 4. Foley catheterization Lacerations of the cervix or vagina may be present when bright red vaginal bleeding persists in the presence of a well-contracted uterus. The incidence of lacerations is higher among which of the following childbearing women? Select all that apply. 1. Over the age of 35 2. Have not had epidural block 3. Have had an episiotomy 4. Have had a forceps-assisted or vacuum-assisted birth 5. Nulliparous After delivery, it is determined that there is a placenta accreta. Which intervention should the nurse anticipate? 1. 2 L oxygen by mask 2. Intravenous antibiotics 3. Intravenous oxytocin 4. Hysterectomy What is required for any women receiving oxytocin (Pitocin)? 1. CPR 2. Continuous electronic fetal monitoring 3. Administering oxygen by mask 4. Nonstress test The client has delivered a 4200 g fetus. The physician performed a midline episiotomy, which extended into a third-degree laceration. The client asks the nurse where she tore. Which response is best? 1. "The episiotomy extended and tore through your rectal mucosa." 2. "The episiotomy extended and tore up near your vaginal mucous membrane." 3. "The episiotomy extended and tore into the muscle layer." 4. "The episiotomy extended and tore through your anal sphincter." The client is undergoing an emergency cesarean birth for fetal bradycardia. The client's partner has not been allowed into the operating room. What can the nurse do to alleviate the partner's emotional distress? Select all that apply. 1. Allow the partner to wheel the baby's crib to the newborn nursery. 2. Allow the partner to be near the operating room where the newborn's first cry can be heard. 3. Have the partner wait in the client's postpartum room. 4. Encourage the partner to be in the nursery for the initial assessment. 5. Teach the partner how to take the client's blood pressure. The client tells the nurse that she has come to the hospital so that her baby's position can be changed. The nurse would begin to organize the supplies needed to perform which procedure? 1. A version 2. An amniotomy 3. Leopold maneuvers 4. A ballottement A woman has been admitted for an external version. She has completed an ultrasound exam and is attached to the fetal monitor. Prior to the procedure, why will terbutaline be administered? 1. To provide analgesia 2. To relax the uterus 3. To induce labor 4. To prevent hemorrhage The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the client's chart requires immediate intervention? 1. Previous birth by cesarean 2. Frank breech ballotable 3. 37 weeks, complete breech 4. Failed ECV last week A woman is scheduled to have an external version for a breech presentation. The nurse carefully reviews the client's chart for contraindications to this procedure, including which of the following? Select all that apply. 1. Station -2 2. 38 weeks' gestation 3. Abnormal fetal heart rate and tracing 4. Previous cesarean section 5. Rupture of membranes A laboring client's obstetrician has suggested amniotomy as a method for inducing labor. Which assessment(s) must be made just before the amniotomy is performed? 1. Maternal temperature, BP, and pulse 2. Estimation of fetal birth weight 3. Fetal presentation, position, and station 4. Biparietal diameter Amniotomy as a method of labor induction has which of the following advantages? Select all that apply. 1. The danger of a prolapsed cord is decreased. 2. There is usually no risk of hypertonus or rupture of the uterus. 3. The intervention can cause a decrease in pain. 4. The color and composition of amniotic fluid can be evaluated. 5. The contractions elicited are similar to those of spontaneous labor. A laboring client's obstetrician has suggested amniotomy as a method for creating stronger contractions and facilitating birth. The client asks, "What are the advantages of doing this?" What should the nurse cite in response? 1. Contractions elicited are similar to those of spontaneous labor. 2. Amniotomy decreases the chances of a prolapsed cord. 3. Amniotomy reduces the pain of labor and makes it easier to manage. 4. The client will not need an episiotomy. During a visit to the obstetrician, a pregnant client questions the nurse about the potential need for an amniotomy. The nurse explains that an amniotomy is performed to do which of the following? Select all that apply. 1. Stimulate the beginning of labor 2. Augment labor progression 3. Allow application of an internal fetal electrode 4. Allow application of an external fetal monitor 5. Allow insertion of an intrauterine pressure catheter After inserting prostaglandin gel for cervical ripening, what should the nurse do? 1. Apply an internal fetal monitor. 2. Insert an indwelling catheter. 3. Withhold oral intake and start intravenous fluids. 4. Place the client in a supine position with a right hip wedge. Under which circumstances would the nurse remove prostaglandin from the client's cervix? Select all that apply. 1. Contractions every 5 minutes 2. Nausea and vomiting 3. Uterine tachysystole 4. Cardiac tachysystole 5. Baseline fetal heart rate of 140-148 The nurse knows that the Bishop scoring system for cervical readiness includes which of the following? Select all that apply. 1. Fetal station 2. Fetal lie 3. Fetal presenting part 4. Cervical effacement 5. Cervical softness The nurse knows that a contraindication to the induction of labor is which of the following? 1. Placenta previa 2. Isoimmunization 3. Diabetes mellitus 4. Premature rupture of membranes Induction of labor is planned for a 31-year-old client at 39 weeks due to insulin-dependent diabetes. Which nursing action is most important? 1. Administer 100 mcg of misoprostol (Cytotec) vaginally every 2 hours. 2. Place dinoprostone (Prepidil) vaginal gel and ambulate client for 1 hour. 3. Begin Pitocin (oxytocin) 4 hours after 50 mcg misoprostol (Cytotec). 4. Prepare to induce labor after administering a tap water enema. The client presents for cervical ripening in anticipation of labor induction tomorrow. What should the nurse include in her plan of care for this client? 1. Apply an internal fetal monitor. 2. Monitor the client using electronic fetal monitoring. 3. Withhold oral intake and start intravenous fluids. 4. Place the client in an upright, sitting position. The nurse is explaining induction of labor to a client. The client asks what the indications for labor induction are. Which of the following should the nurse include when answering the client? 1. Suspected placenta previa 2. Breech presentation 3. Prolapsed umbilical cord 4. Hypertension A client at 40 weeks' gestation is to undergo stripping of the membranes. The nurse provides the client with information about the procedure. Which information is accurate? Select all that apply. 1. Intravenous administration of oxytocin will be used to initiate contractions. 2. The physician/CNM will insert a gloved finger into the cervical os and rotate the finger 360 degrees. 3. Stripping of the membranes will not cause discomfort, and is usually effective. 4. Labor should begin within 24-48 hours after the procedure. 5. Uterine contractions, cramping, and a bloody discharge can occur after the procedure. The client is having fetal heart rate decelerations. An amnioinfusion has been ordered for the client to alleviate the decelerations. The nurse understands that the type of decelerations that will be alleviated by amnioinfusion is which of the following? 1. Early decelerations 2. Moderate decelerations 3. Late decelerations 4. Variable decelerations In which clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion? Select all that apply. 1. Placental abruption 2. Meconium-stained fluid 3. Polyhydramnios 4. Variable decelerations 5. Early decelerations The nurse is monitoring a client who is receiving an amnioinfusion. Which assessments must the nurse perform to prevent a serious complication? Select all that apply. 1. Color of amniotic fluid 2. Maternal blood pressure 3. Cervical effacement 4. Uterine resting tone 5. Fluid leaking from the vagina The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement by the client indicates that further information is required? 1. "Because I have a midline episiotomy, I should keep my perineum clean." 2. "I can use an ice pack to relieve some the pain from the episiotomy." 3. "I can take ibuprofen (Motrin) when my perineum starts to hurt." 4. "The tear I have through my rectum is unrelated to my episiotomy." The client requires vacuum extraction assistance. To provide easier access to the fetal head, the physician cuts a mediolateral episiotomy. After delivery, the client asks the nurse to describe the episiotomy. What does the nurse respond? 1. "The episiotomy goes straight back toward your rectum." 2. "The episiotomy is from your vagina toward the urethra." 3. "The episiotomy is cut diagonally away from your vagina." 4. "The episiotomy extends from your vagina into your rectum." The client is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore. Ten minutes after an ice pack is applied, the client asks for another. What is the best response from the nurse? 1. "I'll get you one right away." 2. "You only need to use one ice pack." 3. "You need to leave it off for at least 20 minutes and then reapply." 4. "I'll bring you an extra so that you can change it when you are ready." Major perineal trauma (extension to or through the anal sphincter) is more likely to occur if what type of episiotomy is performed? 1. Mediolateral 2. Episiorrhaphy 3. Midline 4. Medical A client attending a prenatal class asks why episiotomies are performed. The nurse explains that risk factors that predispose women to episiotomies include which of the following? Select all that apply. 1. Large or macrosomic fetus 2. Use of forceps 3. Shoulder dystocia 4. Maternal health 5. Shorter second stage The nurse is training a nurse new to the labor and delivery unit. They are caring for a laboring client who will have a forceps delivery. Which action or assessment finding requires intervention? 1. Regional anesthesia is administered via pudendal block. 2. The client is instructed to push between contractions. 3. Fetal heart tones are consistently between 110 and 115. 4. The client's bladder is emptied using a straight catheter. The need for forceps has been determined. The client's cervix is dilated to 10 cm, and the fetus is at +2 station. What category of forceps application would the nurse anticipate? 1. Input 2. Low 3. Mid 4. Outlet What type of forceps are designed to be used with a breech presentation? 1. Midforceps 2. Piper 3. Low 4. High The physician has determined the need for forceps. The nurse should explain to the client that the use of forceps is indicated because of which of the following? 1. Her support person is exhausted 2. Premature placental separation 3. To shorten the first stage of labor 4. To prevent fetal distress The physicians/CNM opts to use a vacuum extractor for a delivery. What does the nurse understand? 1. There is little risk with vacuum extraction devices. 2. There should be further fetal descent with the first two "pop-offs." 3. Traction is applied between contractions. 4. The woman often feels increased discomfort during the procedure. The client has been pushing for 2 hours and is exhausted. The physician is performing a vacuum extraction to assist the birth. Which finding is expected and normal? 1. The head is delivered after eight "pop-offs" during contractions. 2. A cephalohematoma is present on the fetal scalp. 3. The location of the vacuum is apparent on the fetal scalp after birth. 4. Positive pressure is applied by the vacuum extraction during contractions. The client has been pushing for two hours, and is exhausted. The fetal head is visible between contractions. The physician informs the client that a vacuum extractor could be used to facilitate the delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance? 1. "A small cup will be put onto the baby's head, and a gentle suction will be applied." 2. "I can stop pushing and just rest if the vacuum extractor is used." 3. "The baby's head might have some swelling from the vacuum cup." 4. "The vacuum will be applied for a total of ten minutes or less." The laboring client participated in childbirth preparation classes that strongly discouraged the use of medications and intervention during labor. The client has been pushing for two hours, and is exhausted. The physician requests that a vacuum extractor be used to facilitate the birth. The client first states that she wants the birth to be normal, then allows the vacuum extraction. Following this, what should the nurse assess the client for after the birth? 1. Elation, euphoria, and talkativeness 2. A sense of failure and loss 3. Questions about whether or not to circumcise 4. Uncertainty surrounding the baby's name The nurse is reviewing charts of clients who underwent cesarean births by request in the last two years. The hospital is attempting to decrease costs of maternity care. What findings contribute to increased health care costs in clients undergoing cesarean birth by request? 1. Increased abnormal placenta implantation in subsequent pregnancies 2. Decreased use of general anesthesia with greater use of epidural anesthesia 3. Prolonged anemia, requiring blood transfusions every few months 4. Coordination of career projects of both partners leading to increased income After being in labor for several hours with no progress, a client is diagnosed with CPD (cephalopelvic disproportion), and must have a cesarean section. The client is worried that she will not be able to have any future children vaginally. After sharing this information with her care provider, the nurse would anticipate that the client would receive what type of incision? 1. Transverse 2. Infraumbilical midline 3. Classic 4. Vertical The client demonstrates understanding of the implications for future pregnancies secondary to her classic uterine incision when she states which of the following? 1. "The next time I have a baby, I can try to deliver vaginally." 2. "The risk of rupturing my uterus is too high for me to have any more babies." 3. "Every time I have a baby, I will have to have a cesarean delivery." 4. "I can only have one more baby." In the operating room, a client is being prepped for a cesarean delivery. The doctor is present. What is the last assessment the nurse should make just before the client is draped for surgery? 1. Maternal temperature 2. Maternal urine output 3. Vaginal exam 4. Fetal heart tones A prenatal client asks the nurse about conditions that would necessitate a cesarean delivery. The nurse explains that cesarean delivery generally is performed in the presence of which of the following? Select all that apply. 1. Complete placenta previa 2. Placental abruption 3. Umbilical cord prolapse 4. Precipitous labor 5. Failure to progress A client is consulting a certified nurse-midwife because she is hoping for a vaginal birth after cesarean (VBAC) with this pregnancy. Which statement indicates that the client requires more information about VBAC? 1. "I can try a vaginal birth because my uterine incision is a low segment transverse incision." 2. "The vertical scar on my skin doesn't mean that the scar on my uterus goes in the same direction." 3. "There is about a 90% chance of giving birth vaginally after a cesarean." 4. "Because my hospital has a surgery staff on call 24 hours a day, I can try a VBAC there." The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which statement by a participant indicates that additional information is needed? 1. "Because the scar on my belly goes down from my navel, I am not a candidate for a VBAC." 2. "My first baby was in a breech position, so for this pregnancy, I can try a VBAC if the baby is head-down." 3. "Because my hospital is so small and in a rural area, they won't let me attempt a VBAC." 4. "The rate of complications from VBAC is lower than the rate of complications from a cesarean." The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal? Select all that apply. 1. Respiratory rate of 66 breaths per minute 2. Periodic breathing with pauses of 25 seconds 3. Synchronous chest and abdomen movements 4. Grunting on expiration 5. Nasal flaring A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding? 1. Call the physician. 2. Administer oxygen. 3. Document the finding. 4. Place the newborn under the radiant warmer. The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? 1. Respiratory rate 60 and irregular in depth and rhythm 2. Pulse rate 145, cardiac murmur heard 3. Mean blood pressure 55 mm Hg 4. Pauses in respiration lasting 30 seconds The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse? 1. 60 breaths per minute 2. 70 breaths per minute 3. 64 breaths per minute 4. 20 breaths per minute Marked changes occur in the cardiopulmonary system at birth include which of the following? Select all that apply. 1. Closure of the foramen ovale 2. Closure of the ductus venosus 3. Mean blood pressure of 31 to 61 mmHg in full-term resting newborns 4. Increased systemic vascular resistance and decreased pulmonary vascular resistance 5. Opening of the ductus arteriosus The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching? 1. "My baby isn't getting enough iron from my breast milk." 2. "Babies undergo physiologic anemia of infancy." 3. "This results from dilution because of the increased plasma volume." 4. "Delaying the cord clamping did not cause this to happen." Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant? 1. Fewer infants require blood transfusion for anemia 2. Fewer infants require blood transfusion for high blood pressure 3. Increase in the incidence of intraventricular hemorrhage 4. Increase in incidence of infant breastfeeding In utero, what is the organ responsible for gas exchange? 1. Umbilical vein 2. Placenta 3. Inferior vena cava 4. Right atrium A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability? Select all that apply. 1. Newborns have less subcutaneous fat than do adults. 2. Infants have a thick epidermis layer. 3. Newborns have a large body surface to weight ratio. 4. Infants have increased total body water. 5. Newborns have more subcutaneous fat than do adults. The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Select all that apply. 1. "We should keep our home air-conditioned so the baby doesn't overheat." 2. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." 3. "When we change the baby's diaper, we should change any wet clothing or blankets, too." 4. "If the baby's body temperature gets too low, he will warm himself up without any shivering." 5. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough." The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss? 1. Placing the newborn away from air currents 2. Pre-warming the examination table 3. Drying the newborn thoroughly 4. Removing wet linens from the isolette The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? 1. Conjugated bilirubin is eliminated in the conjugated state. 2. Unconjugated bilirubin is neurotoxic, and cannot cross the placenta. 3. Total bilirubin is the sum of the direct and indirect levels. 4. Hyperbilirubinemia is a decreased total serum bilirubin level. A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first? 1. Stool characteristics 2. Fluid intake 3. Skin color 4. Bilirubin level The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother? 1. Physiologic jaundice is normal, and peaks at this age. 2. The newborn's liver is not working as well as it should. 3. The baby is yellow because the bowels are not excreting bilirubin. 4. The yellow color indicates that brain damage might be occurring. A newborn is determined to have physiological jaundice. The nurse explains the steps involved in conjugation and excretion of bilirubin to the parents. Which factors would the nurse include in the explanation? Select all that apply. 1. At birth, the newborn's liver begins to conjugate bilirubin or convert it from a yellow lipid-soluble pigment to a water-soluble pigment. 2. Unconjugated bilirubin can leave the bloodstream and enter the tissues, causing a yellow hue to the skin and sclera. 3. Unconjugated bilirubin results from the destruction of white blood cells. 4. The infant is able to excrete conjugated bilirubin, but not unconjugated bilirubin. 5. The newborn's liver has greater metabolic and enzymatic activity at birth than does an adult liver, increasing the newborn's susceptibility to jaundice. The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them? 1. "Jaundice is uncommon in newborns." 2. "Some newborns require phototherapy." 3. "Jaundice is a medical emergency." 4. "Jaundice is always a sign of liver disease." Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels? 1. Monitor urine for amount and characteristics. 2. Encourage late feedings to promote intestinal elimination. 3. All infants should be routinely monitored for iron intake. 4. Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above. Clinical risk factors for severe hyperbilirubinemia include which of the following? Select all that apply. 1. African American ethnicity 2. Female gender 3. Cephalohematoma 4. Bruising 5. Assisted delivery with vacuum or forceps The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse? 1. "The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion." 2. "The infant received too many red blood cells after delivery because the cord was not clamped immediately." 3. "The yellow color of your baby's skin indicates that you are breastfeeding too often." 4. "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should." Which of the following is the primary carbohydrate in the breastfeeding newborn? 1. Glucose 2. Fructose 3. Lactose 4. Maltose At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight? 1. This weight loss is excessive. 2. This weight loss is within normal limits. 3. This weight gain is excessive. 4. This weight gain is within normal limits. A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? 1. "I can't believe he can already digest fats, carbohydrates, and proteins." 2. "It is amazing that his whole digestive tract can move things along at birth." 3. "Incredibly, his stomach capacity was already a cupful when he was born." 4. "He will lose some weight but then miraculously regain it by about 10 days A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurse's best response? 1. "Take your newborn to the pediatrician." 2. "There might be a possible food allergy." 3. "Your newborn has diarrhea." 4. "This is a normal occurrence." A newborn who has not voided by 48 hours after birth should be assessed for which of the following? Select all that apply. 1. Restlessness 2. Pain 3. Kidney distention 4. Adequacy of fluid intake 5. Lethargy The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary? 1. "Our baby was born with kidneys that are too small." 2. "A baby's kidneys don't concentrate urine well for several months." 3. "Feeding our baby frequently will help the kidneys function." 4. "Kidney function in an infant is very different from that in an adult." The student nurse notices that a newborn weighs less today compared with the newborn's birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following? 1. A shift of intracellular water to extracellular spaces. 2. Loss of meconium stool. 3. A shift of extracellular water to intracellular spaces. 4. The sleep-wake cycle. Which of the following would be considered normal newborn urinalysis values? Select all that apply. 1. Color bright yellow 2. Bacteria 0 3. Red blood cells (RBC) 0 4. White blood cells (WBC) more than 4-5/hpf 5. Protein less than 5-10 mg/dL The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didn't I see that he was so sick?" What is the nurse's best reply? 1. "Newborns have immature immune function at birth, and illness is very hard to detect." 2. "Your mothering skills will improve with time. You should take the newborn class." 3. "Your baby didn't get enough active acquired immunity from you during the pregnancy." 4. "The immunity your baby gets in utero doesn't start to function until he is 4 to 8 weeks old." Which nonspecific immune mechanism has the ability of antibodies and phagocytic cells to clear pathogens from an organism? 1. Complement 2. Coagulation 3. Inflammatory response 4. Phagocytosis Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do? 1. Enable T or B cells to respond to antigens 2. Repress responses to specific B or T lymphocytes to antigens 3. Kill foreign or virus-infected cells 4. Remove pathogens and cell debris The student nurse notices that the newborn seems to focus on the mother's eyes. The nursing instructor explains that this newborn behavior is which of the following? 1. Habituation 2. Orientation 3. Self-quieting 4. Reactivity A new father asks the nurse to describe what his baby will experience while sleeping and awake. What is the best response? 1. "Babies have several sleep and alert states. Keep watching and you'll notice them." 2. "You might have noticed that your child was in an alert awake state for an hour after birth." 3. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." 4. "Birth is hard work for babies. It takes them a week or two to recover and become more awake." A new mother is holding her 2-hour-old son. The delivery occurred on the due date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurse's best response? 1. "Don't worry. Babies go through a lot of these little phases." 2. "Your son is in the sleep phase. He'll wake up soon." 3. "Your son is exhausted from being born, and will sleep 6 more hours." 4. "Your breastfeeding efforts have caused excessive fatigue in your son." The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement by a parent indicates that teaching was effective? 1. "My baby will be able to focus on my face when she is about a month old." 2. "My baby might startle a little if a loud noise happens near him." 3. "Newborns prefer sour tastes." 4. "Our baby won't have a sense of smell until she is older." The nurse is teaching a group of new parents about newborn behavior. Which statement made by a parent would indicate a need for additional information? 1. "Sleep and alert states cycle throughout the day." 2. "We can best bond with our child during an alert state." 3. "About half of the baby's sleep time is in active sleep." 4. "Babies sleep during the night right from birth." When providing anticipatory guidance to a new mother, what information does the nurse convey about the newborn's neurologic and sensory/perceptual functioning? Select all that apply. 1. Newborns respond to and interact with the environment in a predictable pattern of behavior, reacting differently to a variety of stresses. 2. The usual position of the newborn is with extremities partially flexed, legs near the abdomen. 3. Newborns do not react to bright light, and their eye movements do not permit them to fixate on faces or objects until they are 3 months of age. 4. Newborns have the capacity to utilize self-quieting behaviors to quiet and comfort themselves. 5. The newborn is very sensitive to being touched, cuddled, and held. A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth? 1. Arm recoil 2. Square window sign 3. Scarf sign 4. Popliteal angle Before the nurse begins to dry off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool? 1. Amount and area of vernix coverage 2. Creases on the sole 3. Size of the areola 4. Body surface temperature A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on which characteristics? Select all that apply. 1. The mass appeared on the second day after birth. 2. The mass appears larger when the newborn cries. 3. The head appears asymmetrical. 4. The mass appears on only one side of the head. 5. The mass overrides the suture line. The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following? 1. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline 2. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body 3. Ear cartilage folded over, lanugo present over much of the body, slow recoil time 4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment? 1. Lanugo mainly gone, little vernix across the body 2. Prominent clitoris, enlarging minora, anus patent 3. Full areola, 5 to 10 mm bud, pinkish-brown in color 4. Skin opaque, cracking at wrists and ankles, no vessels visible The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? 1. Chest circumference 31.5 cm, head circumference 33.5 cm 2. Chest circumference 30 cm, head circumference 29 cm 3. Chest circumference 38 cm, head circumference 31.5 cm 4. Chest circumference 32.5 cm, head circumference 36 cm A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long? 1. 2 months 2. 2 weeks 3. 1 year 4. 4 months The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following? 1. A normal position 2. A possible chromosomal abnormality 3. Facial paralysis 4. Prematurity The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? 1. Cephalohematoma 2. Mongolian spots 3. Telangiectatic nevi 4. Molding The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. What is the best response by the nurse? 1. "His head is molded from fitting through the birth canal. It will become more round." 2. "We refer to that as 'cone head,' which is a temporary condition that goes away." 3. "It might mean that your baby sustained brain damage during birth, and could have delays." 4. "I think he looks just like you. Your head is much the same shape as your baby's." The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate? 1. Place a gloved finger in the newborn's mouth. 2. Take the vital signs. 3. Wait until the newborn stops crying. 4. Place a hot water bottle in the isolette. The nurse wishes to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use? 1. Brazelton Neonatal Behavioral Assessment Scale 2. New Ballard Score 3. Dubowitz gestational age scale 4. Ortolani maneuver The nurse is completing the gestational age assessment on a newborn while in the mother's postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. What is the nurse's best response? 1. "I'm checking to make sure the baby has all of its parts." 2. "This assessment looks at both physical aspects and the nervous system." 3. "This assessment checks the baby's brain and nerve function." 4. "Don't worry. We perform this check on all the babies." The nurse is making an initial assessment of the newborn. The findings include a chest circumference of 32.5 cm and a head circumference of 33.5 cm. Based on these findings, which action should the nurse take first? 1. Notify the physician. 2. Elevate the newborn's head. 3. Document the findings in the chart. 4. Assess for hypothermia immediately. The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? 1. "The white spots on my baby's nose are called milia, and are harmless." 2. "The whitish cheeselike substance in the creases is vernix, and will be absorbed." 3. "The red spots with a white center on my baby are abnormal acne." 4. "Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician." The nurse is assessing the gestational age of a 1-hour-old newborn. Which physical characteristics does the nurse assess? Select all that apply. 1. Sole creases 2. Amount of breast tissue 3. Amount of lanugo 4. Reflexes 5. Testicular descent During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. The nurse documents this finding as which of the following? 1. Nevus vasculosus 2. Nevus flammeus 3. Telangiectatic nevi 4. A Mongolian spot The mother of a 16-week-old infant calls the clinic concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? 1. "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth." 2. "Bring your infant to the clinic immediately." 3. "This is due to overriding of the cranial bones during labor." 4. "Your baby must be dehydrated." Which of the following is a localized, easily identifiable soft area of the infant's scalp, generally resulting from a long and difficult labor or vacuum extraction? 1. Caput succedaneum 2. Cephalohematoma 3. Molding 4. Depressed fontanelles The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following? 1. Adducting the foot and listening for a click. 2. Moving the foot to midline and determining resistance. 3. Extending the foot and observing for pain. 4. Stimulating the sole of the foot. A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following? Select all that apply. 1. The fontanelles can swell with crying. 2. The fontanelles might be depressed. 3. The fontanelles can pulsate with the heartbeat. 4. The fontanelles might bulge. 5. The fontanelles can swell when stool is passed. The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? 1. The student nurse listens to bowel sounds then assesses the head for skull consistency and size and tension of fontanelles. 2. The student nurse checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate. 3. The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. 4. The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids. Approximately what percentage of the newborn's body weight is water? 1. 5% to 10% 2. 90% to 95% 3. 70% to 75% 4. 50% to 60% What condition is due to poor peripheral circulation? 1. Acrocyanosis 2. Mottling 3. Harlequin sign 4. Jaundice The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Select all that apply. 1. Lanugo abundant over shoulders and back 2. Plantar creases over entire sole 3. Pinna of ear springs back slowly when folded. 4. Vernix well distributed over entire body 5. Testes are pendulous, and the scrotum has deep rugae A breastfeeding mother calls the pediatric clinic concerned about her 4-day-old baby's failure to gain weight. She states that the infant has lost several ounces since birth. The most appropriate response by the nurse would be which of the following? Select all that apply. 1. "Newborns tend to lose about 5% to 10% of their birth weight because of failure to give adequate supplements when breastfeeding." 2. "Newborns grow approximately 1 inch a month in the first 6 months. You will need to increase feedings to compensate for the growth spurt." 3. "Newborns have an initial weight loss in the first 3 to 4 days. Your baby's weight loss is normal." 4. "Newborns lose a lot of heat, so make sure you keep the baby's formula warm when you supplement the breast milk." 5. "Keep the baby from getting chilled or too warm because that can contribute to weight loss." The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following? 1. Ortolani maneuver 2. Palmar grasping reflex 3. Clavicle 4. Tonic neck reflex The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention? 1. At rest, the infant has partially flexed arms and the legs drawn up to the abdomen. 2. When the corner of the mouth is touched, the infant turns the head that direction. 3. The infant blinks when the exam light is turned on over the face and body. 4. The right arm is flaccid while the infant brings the left arm and fist upward to the head. Which of the following are important behaviors to assess in the neurologic assessment? Select all that apply. 1. State of alertness 2. Active posture 3. Quality of muscle tone 4. Cry 5. Motor activity When doing a neurologic assessment of a newborn, what would the nurse recognize? Select all that apply. 1. Muscle tone is assessed by moving various parts of the newborn's body while the newborn's head remains in a neutral position. 2. The newborn is somewhat hypertonic. 3. Muscle tone should be symmetrical. 4. Shortly after birth, the infant is flaccid at rest. 5. Diminished muscle tone requires further evaluation. The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following? 1. "My baby might open her arms wide and pull her legs up to her tummy if she is passing gas." 2. "When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still. 3. "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on." 4. "I can get my baby to turn his head toward the right if I lift his right arm over his head." The nurse is working with a mother who has just delivered her third child at 33 weeks' gestation. The mother says to the nurse, "This baby doesn't turn his head and suck like the older two children did. Why?" What is the best response by the nurse? 1. "Every baby is different. This is just one variation of normal that we see on a regular basis." 2. "This baby might not have a rooting or sucking reflex because she is premature." 3. "When she is wide awake and alert, she will probably root and suck even if she is early." 4. "She might be too tired from the birthing process and need a couple of days to recover." A mother notices that her newborn is able to sleep without waking even when in the nursery with other newborns crying. The mother asks whether her baby might have a hearing problem because her father wears hearing aids. What should the nurse explain? 1. Newborn risk factors associated with potential hearing loss do not include a family history of hearing loss. 2. Newborns cannot hear, due to mucus accumulated in the middle ear, which takes several days to drain. 3. Newborns who are asleep do not respond to loud noises that are not accompanied by vibrations. 4. Newborns in a noisy nursery are able to habituate to the sounds, and might not react unless a sound is sudden or much louder. When assessing a full-term newborn, the nurse notes tremorlike movements. The nurse is aware that further evaluation is indicated to rule out which of the following? Select all that apply. 1. Hyperglycemia 2. Hypoglycemia 3. Hypocalcemia 4. Substance withdrawal 5. Neurologic damage The nurse is cross-training maternal-child health unit nurses to provide home-based care for parents after discharge. Which statements indicate that additional teaching is required? Select all that apply. 1. "The behavioral assessment should be done as soon after birth as possible." 2. "The behavioral assessment can be performed without input from parents." 3. "The behavioral assessment might be incomplete in a 1-hour home visit." 4. "The behavioral assessment includes orientation and motor activity." 5. "The behavioral assessment can detect neurological impairments." The parents of a newborn comment to the nurse that their infant seems to enjoy being held, and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents' learning. Which statement indicates that teaching was effective? 1. "Some babies are easier to deal with than others." 2. "We are lucky to have a baby with a calm disposition." 3. "Our baby spends more time in the active alert phase." 4. "Cuddliness is a social behavior that some babies have." The parents are asking the nurse about their newborn's behavior. The nurse begins to teach the parents about their newborn and involve them in their baby's care. What are these interventions directed at promoting to the parents? Select all that apply. 1. Identification of responses or activities that best meet the special needs of their newborn. 2. Ability to evaluate the neurologic capacity of their newborn. 3. Understanding that the baby's temperament will be the same as their own. 4. Positive attachment experiences. 5. Understanding of the newborn's various behaviors. The nurse is explaining to a new mother that the newborn behavioral assessment includes which of the following? Select all that apply. 1. Habituation 2. Motor activity 3. Self-quieting activity 4. Cuddliness 5. Reflexes The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or younger. Which statement should the nurse include? 1. "Your baby will respond to you the most if you look directly into his eyes and talk to him." 2. "Each baby is different. Don't try to compare your infant's behavior with any other child's behavior." 3. "If the sound level around your baby is high, the baby will wake up and be fussy or cry." 4. "If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy." The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first? 1. Mother of a 2-week-old infant who doesn't make eye contact when talked to 2. Father of a 1-week-old infant who sleeps through the noise of an older sibling 3. Father of a 6-day-old infant who responds more to mother's voice than to father's voice 4. Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand The newborn's cry should have which of the following characteristics? Select all that apply. 1. Medium pitch 2. Shrillness 3. Strength 4. High pitch 5. Lusty The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse? 1. "Circumcision should be undertaken to prevent problems in the future." 2. "Circumcision might decrease the child's risk of developing a urinary tract infection." 3. "Circumcision can sometimes cause complications. What questions do you have?" 4. "Circumcision is painful, and should be avoided unless you are Jewish." The nurse tells a mother that the doctor is preparing to circumcise her newborn. The mother expresses concern that the infant will be uncomfortable during the procedure. The nurse explains that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure include which of the following? Select all that apply. 1. Providing a pacifier 2. Stroking the head 3. Restraining both arms and legs 4. Talking to the infant 5. Giving the infant a sedative before the procedure The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? 1. The infant's mother has group B streptococcal (GBS) disease. 2. The infant's mother had an IV of lactated Ringer's solution. 3. The infant's mother had a labor that lasted 12 hours. 4. The infant's mother had a cesarean birth with her last child. The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing which of the following? Select all that apply. 1. Respiratory rate 2. Skin texture 3. Airway clearance 4. Ability to feed 5. Head weight Prior to conducting the initial assessment of a newborn, the nurse reviews the mother's prenatal record and the delivery record to obtain information concerning possible risk factors for the infant and to anticipate the impact of these factors on the infant's ability to successfully transition to the extrauterine environment. Which information is pertinent to this assessment? Select all that apply. 1. Drug or alcohol use by the father 2. Infectious disease screening results 3. Maternal history of gestational diabetes 4. Prolonged rupture of the membranes 5. Maternal use of prenatal vitamins The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate? Select all that apply. 1. Administer a dose of 0.5 to 1 mg within 1 hour of birth. 2. Administer the injection subcutaneously. 3. Use a 25-gauge, 5/8-inch needle for the injection. 4. Protect the medication bottle from light. 5. Give vitamin K prior to a circumcision procedure. The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data? 1. Heart rate 120 2. Temperature 96.8°F 3. Respiratory rate 50 4. Temperature 99.6°F In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? 1. Eye prophylaxis medication 2. Drying the newborn 3. Vital signs 4. Vitamin K injection Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin) include which of the following? 1. Massaging eyelids gently following application 2. Irrigating eyes after instillation 3. Using a syringe to apply ointment 4. Instillation is in the upper conjunctival surface of each eye The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about? 1. Neonatal jaundice 2. Neonatal hypothermia 3. Neonatal hyperthermia 4. Respiratory distress A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Select all that apply. 1. Gently massage the site after injection. 2. Use a 22-gauge, 1-inch needle. 3. Inject in the vastus lateralis muscle. 4. Cleanse the site with alcohol prior to injection. 5. Inject at a 45-degree angle. To maintain a healthy temperature in the newborn, which of the following actions should be taken? Select all that apply. 1. Keep the newborn's clothing and bedding dry. 2. Reduce the newborn's exposure to drafts. 3. Do not use the radiant warmer during procedures. 4. Do not wrap the newborn. 5. Encourage the mother to snuggle with the newborn under blankets. The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? 1. 37-week male, respiratory rate 45 2. 8 pound 1 ounce female, pulse 150 3. Term male, nasal flaring 4. 4-hour-old female who has not voided The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be which of the following? 1. Temperature 97.9°F 2. Respirations 68 breaths/minute 3. Vital signs stable for only 2 hours 4. Heart rate 156 beats/min A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following? 1. "A quick cool bath will help wake up my son for feedings." 2. "I can check my son's temperature under his arm." 3. "My baby should be dressed warmly, with a hat." 4. "Cuddling my son will help to keep him warm." The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Select all that apply. 1. The medication should be instilled in the lower conjunctival sac of each eye. 2. The eyelids should be massaged gently to distribute the ointment. 3. The medication must be given immediately after delivery. 4. The medication does not cause any discomfort to the infant. 5. The medication can interfere with the baby's ability to focus. The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? 1. Keep the infant NPO for 4 hours following the procedure. 2. Observe for urine output. 3. Wrap dry gauze tightly around the penis. 4. Clean with cool water with each diaper change. A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurse's best response? 1. "I will call your pediatrician immediately." 2. "Passage of the first stool within 48 hours is normal." 3. "Your newborn might not have a stool until the third day." 4. "Your newborn must be dehydrated." At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborn's weight is which of the following? 1. Excessive 2. Within normal limits 3. Less than expected 4. Unusual Which instructions should the nurse include when teaching parents of a newborn about caring for the umbilical cord? Select all that apply. 1. Use triple-dye to cleanse the umbilical cord at home. 2. Fold the diaper down to prevent covering the cord stump. 3. Keep the umbilical stump clean and dry to avoid infection. 4. Observe for signs of infection such as foul smell, redness, and drainage. 5. Begin tub baths to help cleanse the cord stump at home. The nurse teaches the parents of an infant who recently was circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur? 1. Wrap the diaper tightly. 2. Clean with warm water with each diaper change. 3. Apply gentle pressure to the site with gauze. 4. Apply a new petroleum ointment gauze dressing. To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following? 1. Keep the baby in the room at all times. 2. Check the identification of all personnel who transport the newborn. 3. Place a "No Visitors" sign on the door. 4. Keep the baby in the nursery at all times. The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what? 1. Hold the newborn in an upright position. 2. Massage the hands and feet. 3. Swaddle the newborn in a blanket. 4. Make eye contact while talking to the newborn. Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following? 1. Preeclampsia screening 2. Congenital kidney disease screening 3. Visual screening 4. Hearing screening Placing the baby at mother's breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated? 1. 6 to 12 hours after birth 2. Within 1 hour of birth 3. 24 hours after birth 4. 48 hours after birth The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern? 1. Large amounts of uric acid crystals in the first days of life 2. At least 6 to 10 wet diapers a day after the first few days of life 3. 1 to 2 stools a day for formula-fed baby 4. Urine that is straw to amber color without foul smell The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs?Select all that apply. 1. Continual rise in temperature 2. Decreased frequency of stools 3. Absence of breathing longer than 20 seconds 4. Lethargy 5. Refusal of two feedings in a row The nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within how long? 1. 2 days 2. 10 days 3. 8 days 4. 14 days New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant? 1. The foreskin will be retractable at 2 months. 2. Retract the foreskin and clean thoroughly. 3. Avoid retracting the foreskin. 4. Use soap and Betadine to cleanse the penis daily. A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurse's best response? 1. "Take your newborn to the pediatrician." 2. "Cover the cord stump with gauze." 3. "Apply Betadine around the cord stump." 4. "This is normal during healing." The nurse is analyzing various teaching strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? 1. Select videos on various topics of newborn care. 2. Organize a class that includes first-time mothers only. 3. Have mothers return in 1 week, when they feel more rested. 4. Schedule time for one-to-one teaching in the mother's room. The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? 1. "I should avoid looking directly into the baby's eyes to prevent frightening the baby." 2. "My baby will be very sleepy immediately after birth and should go to the nursery." 3. "Newborns cannot focus their eyes, so it doesn't matter how I hold my new baby." 4. "Giving the baby his first bath can really give me a chance to get to know him." The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn? 1. "You appear to be Muslim. Do you want your son circumcised?" 2. "Let me explain newborn care here in the United States." 3. "Your baby is a United States citizen. You must be very happy about that." 4. "Could you explain your preferences regarding childrearing?" The nurse is working with an adolescent parent. The adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." What is the best response by the nurse? 1. "You are very young, and parenting will be a challenge for you." 2. "Your mother was probably right. Be very careful with your baby." 3. "Mothers have instincts that kick in when they get their babies home." 4. "We can give the baby's bath together. I'll help you learn how to do it." A mother and her newborn are being discharged 2 days after delivery. The general discharge instructions provided by the nurse include which of the following? Select all that apply. 1. Always place the infant in a supine position in the crib. 2. Support the infant's head when carrying for the first week or two. 3. Do not allow the baby to fall asleep in someone's arms. 4. Cover the cord stump with a bandage. 5. Use a bulb syringe to suction mucus from the infant's nostrils as necessary The nurse is planning home visits to the homes of new parents and their newborns. Which client should the nurse see first? 1. 3-day-old male who received hepatitis B vaccine prior to discharge 2. 4-day-old female whose parents are both hearing-impaired 3. 5-day-old male with light, sticky, yellow drainage on the circumcision site 4. 6-day-old female with greenish discharge from the umbilical cord site The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information? 1. "The baby should be in the back seat." 2. "Newborns must be in rear-facing car seats." 3. "We need instruction on how to use the car seat before installing it." 4. "We can bring the baby home from the hospital without a car seat as it is only a short drive home." The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching? 1. "Call your pediatrician if the baby's temperature is below 98.6°F axillary." 2. "Your baby's stools will change to a greenish color when your milk comes in." 3. "You can wipe away any eye drainage that might form." 4. "Your infant should wet a diaper at least 6 times per day." Which of the following activities allows the nurse to provide individualized parent teaching on the maternal-infant unit? Select all that apply. 1. Teach by example and role modeling when caring for the newborn in the client's room. 2. Teach at every opportunity, even during the night shift, if the occasion arises. 3. Teach using newborn care videos and group classes. 4. Teach using the 24-hour educational television channels in the client's room. 5. Teach using one-to-one instruction while in the client's room. The nurse is providing discharge teaching to the parents of a newborn. The nurse should instruct the parents to notify the healthcare provider in case of which of the following? Select all that apply. 1. More than one episode of forceful vomiting. 2. More than 6 to 10 wet diapers per day. 3. A bluish discoloration of the skin with or without a feeding. 4. Refusal of two feedings in a row. 5. Development of eye drainage. A nurse is evaluating the diet plan of a breastfeeding mother. Which beverage is most likely to cause intolerance in the infant? 1. Orange juice 2. Milk 3. Decaffeinated tea 4. Water The nurse is caring for a premature infant in the NICU, and is going to attempt a bottle feeding with thawed breast milk. How long can thawed breast milk be stored in the refrigerator before the nurse must discard it? 1. 4 hours 2. 8 hours 3. 12 hours 4. 24 hours The nurse is teaching a prenatal class about feeding methods. A father-to-be asks the nurse which method, breast or formula, leads to the fastest infant growth and weight gain. Which response by the nurse is best? 1. "In the first 3 to 4 months breastfed babies tend to gain weight faster." 2. "In the first 3 to 4 months there is no difference in weight gain." 3. "In the first 3 to 4 months bottle-fed babies grow faster." 4. "In the first 3 to 4 months growth isn't as important as your comfort with the method." The community nurse is working with poor women who are formula-feeding their infants. Which statement indicates that the nurse's education session was effective? 1. "I should use only soy-based formula for the first year." 2. "I follow the instructions for mixing the powdered formula exactly." 3. "It is okay to add more water to the formula to make it last longer." 4. "The mixed formula can be left on the counter for a day." What is the primary carbohydrate in mammalian milk that plays a crucial role in the nourishment of the newborn? 1. Colostrum 2. Lactose 3. Lactoferrin 4. Secretory IgA When teaching the new mother about the composition of breast milk, the nurse explains that the fat content can range from 30 to 50 grams/liter. Which factors affect the fat content of breast milk? Select all that apply. 1. Maternal parity 2. Duration of pregnancy 3. Stage of lactation 4. Time of day 5. Vitamin C intake The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding? 1. A mother with a poorly balanced diet 2. A mother who is overweight 3. A mother who is HIV positive 4. A mother who has twins Which statements by a breastfeeding class participant indicate that teaching by the nurse was effective? Select all that apply. 1. "Breastfed infants get more skin-to-skin contact and sleep better." 2. "Breastfeeding raises the level of a hormone that makes me feel good." 3. "Breastfeeding is complex and difficult, and I probably won't succeed." 4. "Breastfeeding is worthwhile, even if it costs more overall." 5. "Breastfed infants have fewer digestive and respiratory illnesses." A client at 20 weeks' gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the client indicate that the teaching was successful? 1. "Formula-feeding gives the baby protection from infections." 2. "Breast milk cannot be stored; it has to be thrown away after pumping." 3. "Breastfeeding is more expensive than formula-feeding." 4. "My baby will have a lower risk of food allergies if I breastfeed." A new mother is questioning the nurse about the advantages of breastfeeding her newborn. Which information should the nurse include in the teaching session? Select all that apply. 1. Breast milk has immunological advantages, including varying degrees of protection from bacterial and viral infections. 2. Breastfeeding has been shown to increase maternal-infant attachment. 3. Breastfeeding can be initially supplemented with bottle feedings so that the father does not feel left out of the infant's care. 4. Breastfeeding often causes nipple tenderness, and may be discouraged until healing occurs. 5. Breastfeeding provides a psychologic advantage to the mother, who derives satisfaction knowing that she is providing her infant with the optimal nutritional start in life. What are some of the advantages and disadvantages of formula-feeding that a nurse should discuss with new parents? Select all that apply. 1. The nutritional value of formula depends on the proper preparation/dilution. 2. There is a potential for bacterial contamination during preparation and storage. 3. Both parents can participate in positive parent-infant interaction during feeding. 4. Refrigeration is not necessary if preparing more than one bottle at a time. 5. Formula has higher levels of essential fatty acids, lactose, cystine, and cholesterol than does breast milk. What interventions would the nurse apply to support the breastfeeding mother? Select all that apply. 1. Assist the mother to begin breastfeeding within the first hour after birth. 2. Have the baby returned to the nursery after feeding so that the mother can get adequate rest. 3. Teach the mother to recognize and respond to early infant feeding cues. 4. Inform the mother about community resources that support breastfeeding. 5. Instruct the mother to avoid eating foods that might upset the newborn's stomach Which of the following are potential disadvantages to breastfeeding? Select all that apply. 1. Pain with breastfeeding 2. Leaking milk 3. Equal feeding responsibilities with fathers 4. Vaginal wetness 5. Embarrassment What should the healthcare provider consider when prescribing a medication to a woman who is breastfeeding? Select all that apply. 1. Drug's potential effect on hormone production 2. Amount of drug excreted into the mother's blood 3. Drug's potential adverse effects to the infant 4. Infant's age and health 5. Mother's need for the medication The nurse is teaching a new mother how to encourage a sleepy baby to breastfeed. Which of the following instructions would not be included in that teaching? 1. Providing skin-to-skin contact 2. Swaddling the newborn in a blanket 3. Unwrapping the newborn 4. Allowing the newborn to feel and smell the mother's breast A mother states that her breasts leak between feedings. Which of the following can contribute to the letdown reflex in breastfeeding mothers? 1. Pain with breastfeeding 2. Number of hours passed since last feeding 3. The newborn's cry 4. Maternal fluid intake When a breastfeeding mother complains that her breasts are leaking milk, the nurse can offer which effective intervention? 1. Decrease the number of minutes the newborn is at the breast per feeding. 2. Decrease the mother's fluid intake. 3. Place absorbent pads in the bra. 4. Administer oxytocin. When is breastfeeding contraindicated? 1. Infant has hypertension 2. Mother has a history of treated tuberculosis 3. Mother is HIV positive or has AIDS 4. Mother has a history of treated herpes Which of the following functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs? 1. ABM 2. WIC 3. ILCA 4. LLLI The nurse is performing an assessment on an infant whose mother states that she feeds the infant in a supine position by propping the bottle. Based on this information, what would the nurse include in the assessment? 1. Otoscopic exam of the eardrum 2. Bowel sounds 3. Vital signs 4. Skin assessment The nurse is working with a new mother who delivered yesterday. The mother has chosen to breastfeed her infant. Which demonstration of skill is the best indicator that the client understands breastfeeding? 1. She puts the infant to breast when he is asleep to help wake him up. 2. She takes off her gown to achieve skin-to-skin contact. 3. She leans toward the infant so that he turns his head to access the nipple. 4. The infant is crying when he is brought to the breast. A new mother who is breastfeeding tells the nurse that her infant is spitting up frequently, has very loose stools and copious gas, and feeds for only short periods of time. The nurse suspects a feeding intolerance and, after questioning the mother about her diet, suggests that she do which of the following? 1. Stop breastfeeding and switch to formula. 2. Eliminate dairy products from her diet. 3. Supplement breastfeeding with a soy-based formula. 4. Offer the baby water between feedings. Which of the following is a sign of dehydration in the newborn? 1. Slow, weak pulse 2. Soft, loose stools 3. Light colored, concentrated urine 4. Depressed fontanelles The nurse is assisting a mother to bottle-feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should do which of the following? 1. Offer a pacifier 2. Burp the newborn 3. Unwrap the newborn 4. Stroke the newborn's spine and feet The nurse is explaining the nutritional differences between breast milk and formula to an expectant couple. The mother-to-be asks whether breast milk is nutritionally superior to formula. What should the nurse reply? 1. The vitamins and minerals in formula are more bioavailable to the infant. 2. There is no cholesterol in breast milk. 3. The only carbohydrate in breast milk is lactose. 4. The ratio of whey to casein proteins in breast milk changes to meet the nutritional needs of the growing infant. The nurse is caring for a new breastfeeding mother who is from Pakistan. The nurse plans her care so that the newborn is offered the breast on which of the following? 1. Day of birth 2. First day after birth 3. Second day after birth 4. Third to fourth day after birth The nurse is working with a client from Southeast Asia. The client tells the nurse that she should not put the baby to breast until her milk comes in and her breasts are warm, because "cold milk" (colostrum) is bad for the baby. After the nurse explains the benefits of colostrum, the client still insists that "cold milk" is bad. Which response by the nurse is best? 1. "What kind of formula would you like to use?" 2. "That idea is folklore. Colostrum is good for the baby." 3. "Now that you are here, you need to feed your baby the right way." 4. "Let's give the baby formula after you breastfeed." A client from Mexico has just delivered a son, and the nurse offers to assist in putting the baby to breast. Although the client indicated before the birth that she wanted to breastfeed, she is very hesitant, and says she would like to bottle-feed for the first few days. After talking to her, the nurse understands that her primary reason for wanting to delay breastfeeding is based on what cultural belief? 1. Breast milk causes skin rashes. 2. It is harmful to breastfeed immediately. 3. Colostrum is bad for the baby. 4. Thin milk causes diarrhea. The nurse is preparing a class on breastfeeding for pregnant women in their first trimester. The women are from a variety of cultural backgrounds, and all speak English well. Which statement should the nurse include in this presentation? 1. "Although some cultures believe colostrum is not good for the baby, it provides protection from infections and helps the digestive system to function." 2. "Some women are uncomfortable with exposing their breasts to nurse their infant, but it really isn't a big deal. You will get used to it." 3. "No religion prescribes a feeding method, so you all can choose whatever method makes the most sense to you." 4. "In most cultures, it is culturally acceptable to speak about intimate matters in front of their families." The nurse has completed a community education session on growth patterns of infants. Which statement by a participant indicates that additional teaching is needed? 1. "Newborns should regain their birth weight by 1 week of age." 2. "Breastfed and formula-fed babies have different growth rates." 3. "Formula-fed infants regain their birth weight earlier than breastfed infant." 4. "Healthcare providers consider breastfeeding to be the 'gold standard' for neonatal nutrition." A nurse is evaluating the diet plan of a breastfeeding mother, and determines that her intake of fruits and vegetables is inadequate. The nurse explains that the nutritional composition of the mother's breast milk can be adversely affected by this nutritional inadequacy. Which strategy should the nurse recommend to the mother? 1. Stop breastfeeding 2. Provide newborn supplements to the newborn 3. Offer whole milk 4. Supplement with skim milk The nurse encourages a new mother to feed the newborn as soon as the newborn shows interest. The nurse bases this recommendation on which benefits of early feedings? Select all that apply. 1. Early feedings stimulate peristalsis. 2. Colostrum is thinner than mature milk. 3. Early feedings enhance maternal-infant bonding. 4. Early feedings promote the passage of meconium. 5. Colostrum contains a high number of calories. The nurse is completing the discharge teaching of a young first-time mother. Which statement by the mother requires immediate intervention? 1. "I will put my baby to bed with his bottle so he doesn't get hungry during the night." 2. "My baby will probably have a bowel movement each breastfeeding, and will wet often." 3. "Nursing every 2 to 3 hours is normal, for a total of 8 to 12 feedings every day." 4. "I will drink fenugreek tea from my grandmother to prevent my milk from coming in." What information should the nurse include when teaching a new mother how to successfully bottle-feed her newborn? 1. Proper dilution of powdered formula is essential to provide adequate nutrition. 2. Keep formula at room temperature for at least 4 hours to warm it, instead of microwaving it. 3. Use enough water to dilute the nutrient and calorie density so the infant will drink more formula. 4. Freeze newly prepared formula for up to 3 months. What are the nurse's responsibilities when teaching the new mother about infant feeding? Select all that apply. 1. The nurse should be well informed about infant nutrition and feeding methods. 2. The nurse should provide accurate and consistent information. 3. The nurse should use each interaction to support the parents and promote the family's sense of confidence. 4. The nurse should familiarize the mother with information about community resources that might be helpful after discharge. 5. The nurse should aggressively promote breastfeeding, even if the parents have decided to bottle-feed their infant. The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn? 1. Offer early feedings with formula or breast milk. 2. Provide glucose water exclusively. 3. Evaluate blood glucose levels at 12 hours after birth. 4. Assess for hypothermia. The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? 1. 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory 2. 23-year-old of low socioeconomic status, unmarried 3. 16-year-old who began prenatal care at 30 weeks 4. 28-year-old with a history of gestational diabetes The nurse is caring for a prenatal client. Reviewing the client's pregnancy history, the nurse identifies risk factors for an at-risk newborn, including which of the following? Select all that apply. 1. The mother's low socioeconomic status 2. Maternal age of 26 3. Mother's exposure to toxic chemicals 4. More than three previous deliveries 5. Maternal hypertension The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart? 1. Preterm appropriate for gestational age, symmetrical IUGR 2. Term small for gestational age, symmetrical IUGR 3. Preterm small for gestational age, asymmetrical IUGR 4. Preterm appropriate for gestational age, asymmetrical IUGR A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? 1. Monitor for feeding difficulties. 2. Assess for facial paralysis. 3. Monitor for signs of hyperglycemia. 4. Maintain a warm environment. The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority? 1. Obtain a blood calcium level. 2. Take the newborn's temperature. 3. Obtain a bilirubin level. 4. Place a pulse oximeter on the newborn. A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dL. What is the best nursing action? 1. To recheck the blood sugar in 6 hours 2. To begin an IV of 10% dextrose 3. To feed the baby 1 ounce of formula 4. To document the findings in the chart The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurse's plan of care for this newborn? 1. Offer early feedings. 2. Administer an intravenous infusion of glucose. 3. Assess for hypercalcemia. 4. Assess for hyperbilirubinemia immediately after birth. The nurse is caring for an infant of a diabetic mother. Which potential complications would the nurse consider in planning care for this newborn? Select all that apply. 1. Tremors 2. Hyperglycemia 3. Hyperbilirubinemia 4. Respiratory distress syndrome 5. Birth trauma The nurse caring for a postterm newborn would not perform what intervention? 1. Providing warmth 2. Frequently monitoring blood glucose 3. Observing respiratory status 4. Restricting breastfeeding The pregnant client at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best? 1. "Babies can develop postmaturity syndrome, which increases their chances of having complications after birth." 2. "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." 3. "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." 4. "The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger." The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurse's best response? 1. "Most newborns are nose breathers." 2. "The tube will elicit the sucking reflex." 3. "A smaller catheter is preferred for feedings." 4. "Most newborns are mouth breathers." A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. Due to oxygen therapy, the nurse explains to the parents, their infant is at a greater risk for which of the following? 1. Visual impairment 2. Hyperthermia 3. Central cyanosis 4. Sensitive gag reflex A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU? Select all that apply. 1. Schedule care throughout the day. 2. Silence alarms quickly. 3. Place a blanket over the top portion of the incubator. 4. Do not offer a pacifier. 5. Dim the lights. The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. Which of the following assessment findings is not congruent with prematurity? 1. Cry is weak and feeble 2. Clitoris and labia minora are prominent 3. Strong sucking reflex 4. Lanugo is plentiful The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statements by the parents indicate that additional teaching is needed? Select all that apply. 1. "Our baby will be in an incubator to keep him warm." 2. "Breathing might be harder for our baby because he is early." 3. "The growth of our baby will be faster than if he were term." 4. "Tube feedings will be required because his stomach is small." 5. "Because he came early, he will not produce urine for 2 days." The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? 1. The new nurse holds the infant after giving a gavage feeding. 2. The new nurse provides skin-to-skin care. 3. The new nurse provides care when the baby is awake. 4. The new nurse gives the feeding with room-temperature formula. Benefits of skin-to-skin care as a developmental intervention include which of the following? Select all that apply. 1. Routine discharge 2. Stabilization of vital signs 3. Increased periods of awake-alert state 4. Decline in the episodes of apnea and bradycardia 5. Increased growth parameters In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include which of the following? Select all that apply. 1. Volume of urine output 2. Weight 3. Blood pH 4. Head circumference 5. Bowel sounds The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority? 1. Tissue Integrity, Impaired 2. Infection, Risk for 3. Gas Exchange, Impaired 4. Family Processes, Dysfunctional The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. What information does teaching include? 1. Specially prepared formulas 2. Cataract problems 3. Low glucose concentrations 4. Administration of thyroid medication The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with which of the following? 1. Omphalocele 2. Gastroschisis 3. Diaphragmatic hernia 4. Myelomeningocele The nurse is caring for a newborn with full fontanelles and "setting sun" eyes. Which nursing interventions should be included in the care plan? Select all that apply. 1. Measure head circumference daily. 2. Assess for bulging fontanelles. 3. Avoid position changes. 4. Watch for signs of infection. 5. Use a gel pillow under the head. During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following? 1. Place the newborn in a prone position. 2. Limit feedings to three a day to decrease diarrhea. 3. Place the infant supine and operate a home apnea-monitoring system. 4. Wean the newborn off the pacifier. The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse? 1. Occasional watery stools 2. Spitting up after feeding 3. Jitteriness and irritability 4. Nasal stuffiness Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? 1. "Our baby's heart murmur is from this syndrome." 2. "He might be a fussy baby because of this." 3. "His face looks like it does due to this problem." 4. "Cuddling and rocking will help him stay calm." The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? Select all that apply. 1. Hyperirritability 2. Decreased muscle tone 3. Exaggerated reflexes 4. Low pitched cry 5. Transient tachypnea In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? 1. Allow extra time with feedings. 2. Assign different personnel to the newborn each day. 3. Place the newborn in a well-lit room. 4. Monitor for hyperthermia. The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for the newborn at home. Which instructions should the nurse emphasize? Select all that apply. 1. Use proper hand-washing technique. 2. Provide three feedings per day. 3. Place soiled diapers in a sealed plastic bag. 4. Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. 5. Take the temperature rectally. A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant? 1. Test with a HIV serologic test at 8 months. 2. Begin prophylactic AZT (Zidovudine) administration. 3. Provide 4 to 5 large feedings throughout the day. 4. Encourage the mother to breastfeed the child. An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care for the newborn at home. Which instructions should the nurse include? 1. Do not add food supplements to the baby's diet. 2. Place soiled diapers in a sealed plastic bag. 3. Wash soiled linens in cool water with bleach. 4. Shield the baby's eyes from bright lights. Many newborns exposed to HIV/AIDS show signs and symptoms of disease within days of birth that include which of the following? Select all that apply. 1. Swollen glands 2. Hard stools 3. Smaller than average spleen and liver 4. Rhinorrhea 5. Interstitial pneumonia The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect? 1. Apical heart rate of 140 beats per minute 2. Respiratory rate of 40 3. Temperature of 36.5°C 4. Visible, blue discoloration of the skin The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents do not seem to understand the explanation given by the physician. What statement by the nurse is best? 1. "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." 2. "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder." 3. "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart." 4. "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal." Which assessment findings would lead the nurse to suspect that a newborn might have a congenital heart defect? Select all that apply. 1. Cyanosis 2. Heart murmur 3. Bradycardia 4. Low urinary outputs 5. Tachypnea The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parent indicates that teaching was effective? 1. "This condition occurs more frequently among Japanese people." 2. "We must be very careful to avoid most proteins to prevent brain damage." 3. "Carbohydrates can cause our baby to develop cataracts and liver damage." 4. "Our baby's thyroid gland isn't functioning properly." The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require which of the following? 1. Initial resuscitation 2. Vigorous stimulation at birth 3. Phototherapy immediately 4. An initial feeding of iron-enriched formula A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best? 1. Begin chest compressions. 2. Begin direct tracheal suctioning. 3. Begin bag-and-mask ventilation. 4. Obtain a blood pressure reading. Which fetal/neonatal risk factors would lead the nurse to anticipate a potential need to resuscitate a newborn? Select all that apply. 1. Nonreassuring fetal heart rate pattern/sustained bradycardia 2. Fetal scalp/capillary blood sample pH greater than 7.25 3. History of meconium in amniotic fluid 4. Prematurity 5. Significant intrapartum bleeding During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations? 1. The rise and fall of the chest 2. Sudden wakefulness 3. Urinary output 4. Adequate thermoregulation A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following signs and symptoms would not be characteristic of RDS? 1. Grunting respirations 2. Nasal flaring 3. Respiratory rate of 40 during sleep 4. Chest retractions A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse anticipate? 1. Delivery of the neonate on its side with head up, to facilitate drainage of secretions. 2. Direct tracheal suctioning by specially trained personnel. 3. Preparation for the immediate use of positive pressure to expand the lungs. 4. Suctioning of the oropharynx when the newborn's head is delivered. The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition? 1. Meconium aspiration syndrome 2. Transient tachypnea of the newborn 3. Respiratory distress syndrome 4. Prematurity of the neonate A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment? 1. Decreased urine output 2. Pulmonary vascular resistance increases 3. Increased PCO2 4. Increased urination When planning care for the premature newborn diagnosed with respiratory distress syndrome, which potential complications would the nurse anticipate? Select all that apply. 1. Hypoxia 2. Respiratory alkalosis 3. Metabolic acidosis 4. Massive atelectasis 5. Pulmonary edema Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn? 1. Jitteriness 2. Sucking on fingers 3. Lusty cry 4. Axillary temperature of 98°F A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, what does the nursing instructor tell the student do? 1. Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood. 2. Use a previous puncture site. 3. Cool the heel prior to obtaining blood. 4. Use a sterile needle and aspirate. The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention? 1. Increased skin temperature and respirations 2. Blood glucose level of 45 3. Room-temperature IV running 4. Positioned under radiant warmer Which nursing intervention is appropriate in the management of the preterm infant with hypothermia? Select all that apply. 1. Warm the baby rapidly to reverse the hypothermia. 2. Monitor skin temperature every 2 hours to determine whether the infant's temperature is increasing. 3. Keep IV fluids at room temperature. 4. Initiate efforts to maintain the newborn in a neutral thermal environment. 5. Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following? Select all that apply. 1. Lights can stay on all the time. 2. The eyes do not need to be covered. 3. The lights will need to be removed for feedings. 4. Newborns do not get overheated. 5. Weight loss is not a complication of this system. The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? 1. Eyes are covered, no clothing on, diaper in place 2. Axillary temperature 99.7°F 3. Infant removed from the isolette for breastfeeding 4. Loose bowel movement The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? Select all that apply. 1. Physiologic jaundice occurs after 24 hours of age. 2. Pathologic jaundice occurs after 24 hours of age. 3. Phototherapy increases serum bilirubin levels. 4. The need for phototherapy depends on the bilirubin level and age of the infant. 5. Kernicterus causes irreversible neurological damage. The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse expect? Select all that apply. 1. Jaundice present within the first 24 hours of life 2. Appearance of jaundice symptoms after 24 hours of life 3. Yellowish coloration of the sclera of the eyes 4. Cephalohematoma or excessive bruising 5. Cyanosis The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dL to 16.6 mg/dL in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn? 1. Continue to observe 2. Begin phototherapy 3. Begin blood exchange transfusion 4. Stop breastfeeding The client with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse? 1. "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." 2. "Your body has made antibodies against the baby's blood that are destroying her red blood cells." 3. "The red blood cells of your baby are breaking down because you both have type O blood." 4. "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed." Which of the following are considered risk factors for development of severe hyperbilirubinemia? Select all that apply. 1. Northern European descent 2. Previous sibling received phototherapy 3. Gestational age 27 to 30 weeks 4. Exclusive breastfeeding 5. Infection A newborn is receiving phototherapy. Which intervention by the nurse would be most important? 1. Measurement of head circumference 2. Encouraging the mother to stop breastfeeding 3. Stool blood testing 4. Assessment of hydration status The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? 1. Urine specific gravity is assessed each voiding. 2. Eye coverings are left off to help keep the baby calm. 3. Temperature is checked every 6 hours. 4. The infant is taken out of the isolette for diaper changes. The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? 1. The newborn maintains a normal temperature 2. An increase of serum bilirubin levels 3. Weight loss 4. Skin blanching yellow Which nursing interventions are appropriate when caring for the newborn undergoing phototherapy? Select all that apply. 1. Cover the newborn's eyes at all times, even when not under the lights. 2. Close the newborn's eyelids before applying eye patches. 3. Inspect the eyes each shift for conjunctivitis. 4. Keep the baby swaddled in a blanket to prevent heat loss. 5. Reposition the baby every 2 hours. The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock? Select all that apply. 1. Increased pulse 2. High blood pressure 3. Tachycardia 4. Bradycardia 5. Capillary filling time greater than 3 seconds Mild or chronic anemia in an infant may be treated adequately which of the following? 1. Transfusions with O-negative or typed and cross-matched packed red cells 2. Iron supplements or iron-fortified formulas 3. Steroid therapy 4. Antibiotics or antivirals The nurse caring for a newborn with anemia would expect which initial laboratory data to be included in the initial assessment? Select all that apply. 1. Hemoglobin 2. Hematocrit 3. Reticulocyte count 4. Direct Coombs' test 5. Cord serum OgM What indications would lead the nurse to suspect sepsis in a newborn? 1. Respiratory distress syndrome developing 48 hours after birth 2. Temperature of 97.0°F 2 hours after warming the infant from 97.4°F 3. Irritability and flushing of the skin at 8 hours of age 4. Bradycardia and tachypnea developing when the infant is 36 hours old Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Select all that apply. 1. Obtain skin cultures. 2. Restrict parental visits. 3. Evaluate bilirubin levels. 4. Administer oxygen as ordered. 5. Observe for signs of hypoglycemia. The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best? 1. "I'll bring you to your baby and then leave so you can have some privacy." 2. "Your baby is on a ventilator with 50% oxygen, and has an umbilical line." 3. "I am so sorry this has all happened. I know how stressful this can be." 4. "Your baby is working hard to breathe and lying quite still, and has an IV." The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following? 1. A history of obsessive-compulsive disorder (OCD) 2. Chlamydia 3. Delivered six other children by cesarean section 4. A urinary tract infection (UTI) One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate? 1. Meticulous hand washing and antibiotic eye ointment administration. 2. Intravenous acyclovir (Zovirax) and contact precautions. 3. Cultures of blood and CSF and serial chest x-rays every 12 hours. 4. Parental rooming-in and four intramuscular injections of penicillin. Which findings would the nurse expect when assessing a newborn infected with syphilis? Select all that apply. 1. Rhinitis 2. Fissures on mouth corners 3. Red rash around anus 4. Lethargy 5. Large for gestational age The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is which of the following? 1. "Your newborn likes to be touched." 2. "Stroking the newborn will help with stimulation." 3. "Visits must be scheduled between feedings." 4. "Your baby loves her pink blanket." The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected? 1. "If I had taken better care of myself, this wouldn't have happened." 2. "I've been sleeping very well since I had the baby." 3. "This is probably the doctor's fault." 4. "If I hadn't seen our baby's birth, I wouldn't believe she is ours."