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maternal newborn exam 2

Terms in this set (98)

APGAR: heart rate
0: absent
1: <100
2: >100
APGAR: respiratory rate
0: absent
1: slow, weak
2: good cry
APGAR: muscle tone
0: flaccid
1: some flexion
2: well-flexed
APGAR: reflex irritablility
0: none
1: grimace
2: cry
APGAR: color
0: blue/pale
1: pink, acrocyanosis
2: completely pink
Piaget's Sensorimotor
birth to 2 years

- develop object permanence
Piaget's preoperational
2 to 7 years old

- children can pretend
- can't logic reasonally
Piaget's concrete operations
7 to 12 years old

- able to classify objects
- can think logically and understand analogies
Piaget's formal operations
12 to adulthood

- can use abstract reasoning about hypothetical situations
Erikson: Trust v Mistrust (1st)
if needs are dependably met, infants develop a sense of basic trust
Erikson: autonomy v shame/doubt (2nd)
toddlers learn to exercise will and do things for themselves, or they doubt their abilities
Erikson: initiative v guilt (3rd)
preschoolers learn to initiate tasks and carry out plans, or they feel guilty about efforts to be independent
Erikson: industry vs inferiority (4th)
children learn the pleasure of applying themselves to tasks, or they feel inferior
Erikson: identity v confusion (5th)
teenagers work at refining a sense of self by testing roles and then integrating them to form a single identity, or they become confused about who they are
Erikson: intimacy v isolation (6th)
young adults struggle to form close relationships and to gain the capacity for intimate love, or they feel socially isolate
Erikson: generativity v stagnation (7th)
the middle-age discover a sense of contributing to the world, usually through family and work, or they may feel a lack of purpose
Erikson: integrity v despair (8th)
when reflecting on his or her life, the older adult may feel a sense of satisfaction or failure
types of play
1. observation (infant)
2. parallel (toddler)
3. associative (preschooler)
4. cooperative (school age)
Types/times of lochia
0-3 days: rubra (red)
3-10 days: serosanguinous (pink)
up to 6 weeks: alba (white)
A postpartum woman (gravida 1, para 1) asks the nurse immediately after delivery if she
should request rooming-in with her newborn. Which of the following?
a. This puts too much responsibility on the first time mother
b. It depends on whether you will breastfeed or not.
c. Resting for the first 3 day postpartum will be better for you
d. Rooming-in allows increased maternal-newborn contact
d. rooming-in allows increased maternal-newborn contact
Which action by the mother relates to the nurse that she is accepting her child?
a. She turns her face to meet the newborn's eyes when she holds her
b. She fills out the birth certificate while in the hospital
c. She has many visitors in the room
d. Her husband spends time holding the bab
a. she turns her face to meet the newborn's eyes when she holds her
The nurse is providing discharge teaching to the postpartum client regarding mood
changes to report. In differentiating between the baby blues and postpartum depression,
which of the following statements should be included..
a. Baby blues are the result of hormonal shifts and should resolve by the end of the
sixth postpartum week
b. Baby blues may present in the first few days after birth and resolve prior to
the second postpartum week
c. Postpartum depression may occur on the 5th postpartum day but will resolve
spontaneously by the end of the 6th week.
d. Postpartum depression is the result of hormonal changes related to the end of
pregnancy and will not require intervention or medication managemen
b. baby blues may present in the first few days after birth and resolve prior to the second postpartum week
After delivery, a client is diagnosed with postpartum preeclampsia. What care will the
nurse provide to this client (Select all)
a. Maintain on bed rest with bathroom privileges
b. Monitor urine output and daily weight
c. Instruct on the need for a fluid bolus
d. Administer magnesium sulfate as prescribed
e. Administer antihypertensive medication as prescribed
a, b, d, e
While assessing the newborn's 5 minute apgar score, the nurse notes the following:
heart rate 154, respiratory effort lusty cry, muscle tone well flexed with active movement,
reflex irritability crying vigorously with stimulation, color hands and feet are blue. What score
would she assign to this newborn?
a. 6
b. 7
c. 9
d. 10
c. 9
The nurse is preparing formula for a preterm newborn. Which type of formula will most
likely be prescribed for this client?
a. Glucose water
b. 20 calories per ounce
c. Iron supplemented
d. 24 calorie per ounce
d. 24 calorie per ounce

(20-22 for term infant)
When planning care for a postpartum client, the nurse is aware that which site is the
most common for postpartum infection
a. Milk ducts
b. Urinary bladder
c. Blood stream
d. Reproductive trac
d. reproductive tract
A newborn is jaundiced and receiving phototherapy. Which of the following is an
appropriate intervention when caring for a newborn with hyperbilirubinemia?
a. Apply an oil based lotion to the newborns skin to prevent drying and cracking
b. Change the newborns position every 4 hours
c. Limit the newborns intake of milk to prevent nausea, vomiting, and diarrhea
d. Place eye shields over the newborns closed eyes
d. place eye shields over the newborns closed eyes
The nurse is assessing the fundus on a client on postpartum day 2. What should the
nurse expect when palpating the fundus?
a. Fundus 4 cm above the symphysis pubis and firm
b. Fundus 4 cm below the umbilicus and midline
c. Funs two fingerbreadths above symphysis pubis and firm
d. Fundus two fingerbreadths below the umbilicus and firm
d. fundus two fingerbreadths below the umbilicus and firm

(1 cm per day)
At birth the newborn has dry, cracked skin, absence of vernix, lack of subcutaneous fat,
and fingernails extending beyond the fingertips. Based on these findings...
a. Postterm
b. Preterm
c. SGA
d. LGA
a. postterm

(key is the fingers nails extending beyond fingertips)
By the time children reach their twelfth birthday, they should have learned to trust others
and should have developed a sense of what
a. Integrity
b. Intimacy
c. Identity
d. Industry
d. industry

(integrity is last stage, intimacy of 20s, and identity is teens)
The nurse is preparing a seminar on breastfeeding for a group of pregnant clients.
Which information should the nurse include during the seminar?
a. Uterine involution is slowed by breastfeeding.
b. Breastfeeding enhances bonding with the newborn
c. Breastfeeding might increase the risk of breast cancer
d. Breastfeeding mothers have a decreased risk of developing thrombophlebitis
b. breastfeeding enhances bonding with the newborn
A nurse is assessing a newborn for congenital hip dysplasia. Which signs or symptoms
should be brought to the attention of the health care provider for further assessment? (select
all that apply)
a. Newborn who is actively moving all extremities
b. Newborn has one leg that appears longer than the other
c. Newborn whos bilateral leg length is symmetric
d. Newborn who has extra skin folds on the inner thigh of one leg
e. Newborn who has a click in the hip joint when one hip is maneuvered
b, d, e
Which technique is used to palpate the fundal height on a postpartum client?
a. Placing one hand at the base of the uterus and one on the fundus
b. Placing one hand on the fundus, one on the perineum
c. Resting both hands on the fundus
d. Palpating the fundus with only fingertip pressure
a. placing one hand at the base of the uterus and one on the fundus
Why are postpartum women prone to urinary retention?
a. Catheterization at the time of delivery reduces bladder toxicity.
b. Decreased bladder sensation results from edema because of pressure of
birth.
c. Frequent partial voiding never relieves the bladder pressure
d. Mild dehydration causes a concentrated urine volume in the bladde
b. decreased bladder sensation results from edema because of pressure of birth
A nurse is helping her postpartum client up to the bathroom for the first time after
delivery. Which finding indicates her lochia is normal or expected?
a. Locia contains large clots
b. The flow is over 500 mL
c. Her uterus is boggy and soft
d. The color of the flow is red
d. the color of the flow is red

(should not contain clots, >500 mL, or a soft/boggy uterus)
A newborn with has just returned from surgery to place a gastrostomy tube.Which
nursing diagnosis will the nurse use
a. Risk for imbalanced nutrition
b. Risk for deficient fluid volume
c. Risk for impaired skin integrity
d. Risk for ineffective gas exchange
a. risk for imbalanced nutrition
A newborn was delivered 2 hours ago is being assessed in the nursery. Upon exam, the
nurse notes a flattened nasal bridge, wide cat eyes...?
a. Hemoglobin electrophoresis
b. Chromosomal blood testing
c. CT of the brain
d. Meconium toxicology testing
b. chromosomal blood testing
According to erickson, which stage of development has the developmental task, trust vs
mistrust?
a. Infancy
b. Toddler
c. Early Childhood
d. Adolescence
a. infancy
According to erickson, which stage of development has the developmental task, autonomy vs shame?
a. Infancy
b. Toddler
c. Early Childhood
d. Adolescence
b. toddler
When assessing a newborn, which of the following techniques should the nurse use to
elicit the stepping reflex?
a. Strike a flat surface on which the newborn is lying
b. Place an object in the newborns palm
c. Stroke the outer edge of the sole of the newborns feet up toward the toes.
d. Hold the newborn upright with his feet touching a flat surface.
d. hold the newborn upright with his feet touching a flat surface
The nurse is assisting a new mother to begin breastfeeding. Which action is the most
appropriate for the nurse to take?
a. Positioning the newborn near her breast and stroking his cheek to
encourage him to latch.
b. Stressing that breastfeeding is a normal process and will need minimal help
learning it
c. Cautioning her not to allow the newborn to grasp the areola of her breast to
prevent soreness
d. Encouraging her to lie on her side and help the baby become wide awake by
talking to him
a. positioning the newborn near her breast and stroking his cheek to encourage him to latch
The nurse is inspecting a male newborn genitalia. Which action should the nurse avoid?
a. Inspecting the gential area for irritated skin
b. Inspecting if the urethral opening appears circular
c. Palpating if testes are descended into the scrotal sac
d. Retracting the foreskin over the glans to assess for secretions
d. retracting the foreskin over the glans to assess for secretions

(should NEVER retract the foreskin)
A nurse is assessing a newborn that was admitted to the newborn nursery 28 hours ago.
Mother's history includes addiction to recreational drugs. Which finding would the nurse expect?
a. Sleepiness
b. Flaccid extremities
c. Incessant crying
d. Quiets with swaddling
c. incessant crying
In providing care to the postpartum client, the nurse recognizes that women are
hypercoagulable during the third trimester of pregnancy and that assessment of this client
should include evaluation for the development of venous thromboembolism. Which of the
following should be included in this evaluation? (select all that apply)
a. Observe the distal upper extremities for swelling and edema
b. Observe the lower extremities for symmetry
c. Auscultation of lung sounds
d. Observation of respiratory rate and effort
e. Assessment of uterine cramping
b, c, d
The nurse had instructed a mother on the importance of providing a toddler with a
balanced diet. What observation during a home visit indicates that...?
a. The child is eating a piece of cake and ice cream for lunch
b. A mother prepares a scrambled egg for the toddlers breakfast
c. The mother places a serving of fried finger foods on a plate for the child
d. The child takes candy from a dish that is placed on the coffee table in the living
room
b. a mother prepares scrambled eggs for the toddlers breakfast
n caring for the postpartum client, the nurse will include assessment and observation for
signs of postpartum hemorrhage. Which of the following would put mother at risk?
a. Macrosomic infant
b. dysfunctional or prolonged labor
c. Multiparity
d. Maternal blood type a-
e. History of iron deficiency anemia
a, b, c
Which assessment finding indicates to the nurse that a newborn has hip sublimation?
a. Inward rotation of the right foot
b. Inability for the right hip to abduct
c. Crying on straightened of the right leg
d. Drawing of the legs underneath while prone
b. inability for the right hip to abduct
Which of the following is an advantage of breastfeeding for the newborn
a. Breast milk is more difficult to digest, so it makes the newborn feel fuller longer
b. Breast milk contains antibodies and thus decreases the possibility....
c. It takes less effort for a newborn to suck at a breast than from a bottle
d. Breast milk leads to firmer stools, increasing bowel tone
b. breast milk contains antibodies and thus decreases the possibility of infection
During a home visit, a postpartum client reports fullness and tenderness on the outer
side of her right breast. With light palpation, the nurse feels a small lump with engorgement.
a. Mastitis
b. Breast cancer
c. Plugged milk duct
d. Engorgement
c. plugged milk duct

(palpable lump)
A new mother asks the nurse how soon she can try to breastfeed after delivery. Which of
the following would be the nurse's best response?
a. Immediately after
birth
b. After the newborn is allowed to rest
c. Once the newborn has a first feeding of formula
d. In 24 hours after her newborn is given water
a. immediately after birth
The nurse is teaching new parents how to calculate the amount of formula to feed their
newborn each day. The baby weighs 8 lbs. How Much formula should the nurse teach the
parents to provide
a. 20-24 oz
b. 30 - 36
c. 42 - 54
d. 60 - 72
a. 20-24 oz
postpartum woman is prescribed an antibiotic because of endometritis. Her breast-fed
newborn should be observed particularly to which of the following
a. Decreased sleep levels and increased appetite
b. Jaundice that does not respond to phototherapy
c. Irritability and loss of appetite
d. Signs of thrush and easy bruising
d. signs of thrush and easy bruising
The nurse is evaluating a new mother's ability to effectively breastfeed her newborn.
Which criteria indicates that the mother should be ...(select all that apply)
a. Nipples are everted
b. Breast are soft and nontender
c. Mother holds the newborn close to her breast Phrased "Mother holds
newborn in a football hold"
d. Newborn swallows spontaneously and frequently
e. Nurse places pillows under the baby for support
a, b, c, d
A nurse is caring for a newborn with myelomeningocele. Which of the following actions
should the nurse include in...
a. Assist the caregiver with cuddling the newborn
b. Assess the newborn's temperature rectally
c. Place the newborn in a supine position
d. Apply a sterile, moist dressing on the sac.
d. apply a sterile, moist dressing on the sac
A nurse at a well-baby clinic is collecting data about a nine-month-old infant. The nurse
understands that what occurs at this Stage of development
a. Builds a tower of 2 cubes
b. Walking with one handheld
c. Use of one to three word sentence
d. Fears strangers
d. fears strangers
A nurse is caring for an adolescent whose mother expresses concern about the child
sleeping such long hours. Which of the following is most likely the reason?
a. Sleep terrors
b. Rapid growth
c. elevated magnesium level
d. slowed metabolism
b. rapid growth
A new mother asks the nurse how to determine if the baby is receiving enough breast
milk. How should the nurse respond to the mother
a. The newborn should not become constipated
b. The newborn should sleep at least 3 hours between feedings
c. You need to weigh the newborn before and after each feeding
d. the newborn should gain weight and have six wet diapers daily
d. the newborn should gain weight and have six wet diapers daily
Which of the following actions should the nurse take to prepare the preschool aged child
for a physical examination
a. Allow the child to role play
b. Use medical terminology to describe what will happen
c. Separate the child form the caregiver during the exam
d. Keep medical equipment visible to the child
a. allow the child to role play
The nurse is concerned that a new mother is not showing interest in the newborn and
does not participate in newborn care. What action should the nurse take to help both the
mother and newborn at ...
a. Notify social services department due to neglect to remove the the newborn from
the home
b. Schedule home visit for the mother, newborn, and support person
c. Assess who is going to take care of the baby at home
d. Ask the client if it would be better for the baby to put up for adoption
b. schedule home visit for the mother, newborn, and support person
According to piaget, which basic concept will the child learn during the first year of life?
a. He is not an extension of their parents
b. He cannot be fooled by changing shapes
c. His parents are not perfect
d. Most procedures can be reversed
a. he is not an extension of their parents
A woman who delivered a term neonate 3 days ago is complaining of fever, fatigue, and
heavy vaginal discharge. On assessment, the nurse suspects?
a. Mastitis
b. Urinary tract infection
c. Postpartum hemorrhage
d. Endometritis
d. endometritis
The nurse in the pediatric clinic is recording anthropometric data in the 12-month-old
child's chart. The father asks, is my son growing the way that he should?" Which of the
following nurses response
a. The child's weight will be triple the birth weight by one year of age
b. The child's height should increase by 2 inches per month
c. The child's weight at 12 months should be double the birth weight.
d. Increases in height/length are most rapid from 9-12 months
a. the child's weight will be triple the birth weight by one year of age
A newborn goes through many changes at the time of delivery when transitioning to
extrauterine life. What changes are expected?
a. Acrocyanosis
b. Apnea
c. Atonia
d. Asymmetry
a. acrocyanosis
The nurse is assessing the breast of a woman who is 1 month postpartum. The woman
reports a painful, inflamed area on one breast. Upon assessment, the nurse notes a
wedged-shaped area on one breast to be red and warm to touch. Clients temperature is
101.8. What should the nurse consider is the potential diagnosis?
a. Breast yeast infection
b. Mastitis
c. Plugged milk duct
d. Engorgement
b. mastitis
Hypoglycemia in a mature newborn is denied as a blood glucose level below which
amount?
a. 100 mg/100 mL whole blood
b. 80
c. 40
d. 30
c. 40
The nurse is called to the room of a client who had a term delivery of a 9 lb, 8 oz.
newborn 24 hours ago. The client is noted to have lost consciousness on her way to the
bathroom. which assessment should the nurse
a. Assess ability to void
b. Assess the fundus
c. Assess blood pressure and heart rate
d. call provider
b. assess the fundus (boggy?)
While inspecting a newborn's head, the nurse identifies a swelling of the scalp on the
right posterior side of the head that does not cross the suture line.
a. Caput succedaneum
b. Cephalohematoma
c. Enlarged fontanelle
d. Molding
b. cephalohematoma

(would be caput succedaneum if it crossed the suture line)
The nurse is caring to a postpartum woman 18 hours after the primary cesarean section
for preeclampsia. The client is noted to have a boggy uterus and a moderate to large
amount of vaginal bleeding. The nurse notifies the physician of these findings and expects
an order for what
a. Terbutaline
b. Methergine
c. Misoprostol
d. Magnesium sulfate
c. misoprostol
The nurse observes a mother telling a toddler that pasta and potatoes will make the
child fat. What should the nurse instruct the mother about these food items
a. Toddlers need carbohydrates for brain function
b. It is more important to restrict protein than carbohydrates
c. No more than 30% of all food should be from carbohydrate sources
d. The child should be instructed to restrict carbohydrates after the age of 5 years
a. toddlers need carbohydrates for brain function
The nurse is assessing a term newborn. Which finding should the nurse expect when
assessing the pattern of sole creases
a. Creases on two thirds of the foot
b. Heel creases but no anterior creases
c. Longitudinal but no horizontal creases
d. Creases covering one fourth of the foot
a. creases on two thirds of the foot
A nurse is caring for a 9-month-old with influenza. Which of the following might be a toy
that could be used to interact, play, or distract them from the discomfort.
a. Legos
b. Teddy bear with button eyes
c. large plastic blocks
d. Doll
c. large plastic blocks
During a home visit, a new mother is concerned that after three meconium stools her
newborn is now starting to have yellow seedy stools. What should the nurse explain
a. This is a normal finding
b. This is most likely a symptom of diarrhea
c. The baby may be developing an allergy to breast milk
d. The child will need to be isolated until the stool can be cultured.
a. this is a normal finding
When caring for a newborn several hours after birth, what would the nurse assess as a
normal newborns respiratory rate?
a. 12 to 16 breaths/min
b. 16 to 20 breaths/min
c. 20 to 30 breaths/min
d. 30 to 60 breaths per minute
d. 30 to 60 breaths per minute
The parents of a newborn are concerned that something is wrong with their newborn
eyesight. What should the nurse reassure the parents as being an expected finding in the
newborn?
a. Produces tears when he cries
b. Follows a light to the midline
c. Has a white rather than a red reflex
d. Follows the finger a full 180 degrees
b. follows a light to the midline
A newborn has loose, yellow stools. The newborn appears healthy, but his mother is
concerned that this means he is allergic to breast milk. Which of the following is the..
a. Try burping the newborn more frequently
b. Breastfeed newborns stools are normally loose
c. Consider changing to a soybean formula
d. You may need to have the newborn investigated for bile duct disease
b. breastfed newborns stools are normally loose
The nurse is assessing a client at her 6-week postpartum appointment. The client states
that she feels tired all the time, has trouble falling and staying asleep...
a. Normal postpartum feelings
b. Baby blues
c. Postpartum depression
d. Postpartum psychosis
c. postpartum depression
An infant develops hydrocephalus at 2 weeks of age. Which finding would the nurse
expect to assess?
a. A soft, fretful cry
b. Hypothermia in the late afternoon
c. Bulging fontanels
d. Excessive thirs
c. bulging fontanels
A client recently delivered a newborn and her legs are still numb from the epidural . The
nurse assessed the fundus and found it to be at 1 fingerbreadth above the umbilicus and
deviated to the right. What is the priority nursing ....
a. Administer and IV fluid bolus
b. Perform a straight catheterization to relieve bladder distention
c. Administer pain medication
d. Perform fundal massage and assess lochia color and amount
b. perform a straight cath to relieve bladder distension

(fundus should be midline, is displaced due to full bladder)
The nurse on the postpartum unit is reviewing uterotonic (oxytocic, used to induce labor) medications with a
group of nursing students. Which of the following would be ...
a. Terbutaline
b. Hemabate
c. Magnesium sulfate
d. Phytonadione
b. hemabate (carboprost)
A preterm newborn is placed in a radiant heat warmer immediately after birth. Which of
the following nursing diagnoses is this an intervention for?
a. Ineffective thermoregulation related to immaturity
b. Risk for imbalanced nutrition, less than body requirements
c. Risk for deficient fluid volume related to insensible water loss
d. Impaired gas exchange related to immune pulmonary functioning
a. ineffective thermoregulation related to immaturity
A newborn is prescribed to receive vitamin k 0.5 mg intramuscularly. What should the
nurse do to administer this medication to the newborn?
a. Administer the medication in the deltoid muscle
b. Administer the medication into the vastus lateralis
c. Provide the medication immediately before breastfeeding
d. Notify the physician for swelling and irritation at the injection site.
b. administer the medication into the vastus lateralis
The nurse is called to the room of a client who had a term delivery of a 9 lb, 8 oz
newborn 24 hours ago. The client is noted to have lost consciousness on her way to the
bathroom. Upon assessment the fundus is noted to be boggy and deviated to the left with a
moderate amount of vaginal bleeding. What is the priority nursing action?
a. Massage the fundus
b. Empty the bladder
c. Administer methergine
d. Initiate IV access
a. massage the fundus
A postpartum woman has a fourth-degree perineal laceration. Which of the following
physician orders would the nurse question?
a. An order for PRN docusate sodium
b. Administer of acetaminophen/oxycodone for pain
c. Administer of a sitz bath
d. Administration of an enema
d. administration of an enema

(nothing should be inserted into vagina/rectum after 4th degree)
The nurse instructs the parents of a newborn on actions to prevent sudden infant death
syndrome. Which observation indicates that teaching has been effective?
a. Newborn is placed on the back to sleep
b. Mother removes a pacifier from the baby's mouth
c. The baby is on an every 2 hour formula feeding schedule
d. Parents signed a waiver refusing routing immunizations after birth
a. newborn is placed on the back to sleep
When assessing a newborn, the apgar score determines the ability of the newborn to
transition to extrauterine life. Which of the following does the Apgar score assess
a. Color
b. Heart rate
c. Respiration
d. Gender
e. Birthtime
a, b, c

(along with reflex irritability and muscle tone)
During a home visit, the nurse determines that a toddler has a difficult temperament.
What did the nurse observe in this visit? (select all that apply)
a. Withdrawing
b. Rhythmic
c. Intense mood
d. Menial adaptability
e. negative mood
a, c, d, e
A nurse is caring for a 4-year-old female. Which of the following is expected of a
preschool aged child
a. Describing manifestations of illness
b. Understanding causes of illness
c. Relating fears to magical thinking
d. Awareness of body function
c. relating fears to magical thinking
The nurse provides discharge instructions to a postpartum client who had a vaginal birth.
Which client statement indicates that teaching has been effective?
a. I should limit stair climbing to four times a day
b. I can begin having intercourse when I get home
c. I can return to my full-time job after 6 weeks
d. i should notify the physician if my discharge decreases in amount
c. i can return to my full-time job after 6 weeks
A nurse is caring for a client who has delivered her first newborn less than 24 hours ago.
The newborn has been diagnosed with hyperbilirubinemia.While providing education to the
client on this condition, the nurse should include which of the following has potential causes
of this condition? (select all that apply)
a. Allergy to breast milk
b. Biliary atresia
c. Prenatal alcohol consumption
d. Abo incompatibility
e. Rh isoimmunization (blood group incompatibility)
b, d, e
the nurse is concerned that a new mother is not showing interest in the newborn and does not participate in newborn care. What action should the nurse take to help both the mother and newborn at this time?
a. Notify social services department due to neglect to remove the newborn from the home.
b. Schedule home care for the mother and infant
c. Assess who is going to take care of the baby at home.
d. Ask the patient if it would be better for the baby to put up for adoption.
e. Contact a family member to care for the infant upon discharge
f. Consult a case manager to complete a postpartum assessment
f. consult a case manager to complete a postpartum assessment
Neonatal nurse is assessing a 2hour old male newborn. She notes that the urethra meatus is not midline but is displaced on the dorsal surface (top side) of the penis. What is the medical term for this?
a. undescended testicle
b. hypospadias
c. epispadias
d. varicocele
c. epispadias
a nurse is about to begin an infusion of magnesium sulfate on a patient with preeclampsia. The patient asks why she is on this medication. What is the best response from the nurse?
a) Magnesium will help you to calm down
b) Magnesium is a muscle relaxer
c) Magnesium will help you to urinate
d) Magnesium will help to prevent seizures
d. magnesium will help to prevent seizures
a father is concerned that his 3-day old infants face appears yellow. Which response should the nurse provide to the father?
a) This is mild jaundice due to the immaturity of the baby's liver. We will continue to monitor bilirubin levels.
b) This is a very serious condition. Your infant will be transferred to the neonatal intensive care unit
c) This buildup of bilirubin in the baby occurred because your wife and baby are both negative blood types
d) It would be best to best to switch from breastfeeding to formula feeding to help the baby excrete the bilirubin
a. this is mild jaundice due to the immaturity of the baby's liver. we will continue to monitor bilirubin levels.
a parent is describing to the nurse activities that her 3-year-old preschool child is achieving. The nurse knows that this child is experiencing which task of Erickson's psychosocial stage of development
a) Autonomy vs shame/doubt
b) Initiative vs guilt
c) Trust vs mistrust
d) Industry vs inferiority
b. initiative vs guilt
what is the appropriate definition of a 4th degree perineal laceration?
a. A tear including the entire perineum into the rectum
b. A tear including the vaginal membrane
c. A tear including the labia minora and labia majora
d. A tear including the entire perineum to the sphincter
a. tear including the entire perineum into the rectum
A patient breastfeeding her newborn asks the nurse to assist the infants in obtaining a good latch. Which nursing diagnosis would be most appropriate for the patient?
a. Powerlessness
b. Health-seeking behaviour
c. Readiness for enhanced coping
d. anxiety related to breastfeeding
b. health-seeking behavior
The nurse is planning to instruct a new mother on care of the newborn. Which instructions support the 2020 National Health Goals for the newborn? (Select all that apply.)
A) Place the infant on the back to sleep.
B) Wash the baby's hair at least once a week.
C) Continue to breastfeed the baby until age 6 months.
D) Bath the baby from the most soiled to the cleanest areas.
E) Do not provide the baby with a bottle while falling asleep
a, c
The nurse is assessing the cognitive development of a one-year old infant. Which of the following characteristics would the nurse identify as appropriate development for this age?
a. Thoughts become increasingly logical and queries
b. Able to think about this distance future
c. able to control save on environment
d. object permanence is fully developed
d. object permanence has developed
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