Maternity And Women’s Health Care,11th Edition by Deitra Leonard Lowdermilk -Test Bank

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Maternity And Women’s Health Care,11th Edition by Deitra Leonard Lowdermilk -Test Bank

Chapter 02: Community Care: The Family and Culture

Lowdermilk: Maternity & Women’s Health Care, 11th Edition

 

MULTIPLE CHOICE

 

  1. A married couple lives in a single-family house with their newborn son and the husband’s daughter from a previous marriage. Based on this information, what family form best describes this family?
a. Married-blended family
b. Extended family
c. Nuclear family
d. Same-sex family

 

 

ANS:  A

Married-blended families are formed as the result of divorce and remarriage. Unrelated family members join to create a new household. Members of an extended family are kin or family members related by blood, such as grandparents, aunts, and uncles. A nuclear family is a traditional family with male and female partners along with the children resulting from that union. A same-sex family is a family with homosexual partners who cohabit with or without children.

 

DIF:    Cognitive Level: Remember           REF:   p. 19

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which key factors play the most powerful role in the behaviors of individuals and families?
a. Rituals and customs
b. Beliefs and values
c. Boundaries and channels
d. Socialization processes

 

 

ANS:  B

Beliefs and values are the most prevalent factors in the decision-making and problem-solving behaviors of individuals and families. This prevalence is particularly true during times of stress and illness. Although culture may play a part in the decision-making process of a family, ultimately, values and beliefs dictate the course of action taken by family members. Boundaries and channels affect the relationship between the family members and the health care team, not the decisions within the family. Socialization processes may help families with interactions within the community, but they are not the criteria used for decision making within the family.

 

DIF:    Cognitive Level: Understand          REF:   pp. 21-22       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Using the family stress theory as an interventional approach for working with families experiencing parenting challenges, the nurse can assist the family in selecting and altering internal context factors. Which statement best describes the components of an internal context?
a. Biologic and genetic makeup
b. Maturation of family members
c. Family’s perception of the event
d. Prevailing cultural beliefs of society

 

 

ANS:  C

The family stress theory is concerned with the family’s reaction to stressful events. Internal context factors include elements that a family can control such as psychologic defenses, family structure, and philosophic beliefs and values. The family stress theory focuses on ways that families react to stressful events. Maturation of family members is more relevant to the family life-cycle theory. The family stress theory focuses on internal elements that a family might be able to alter.

 

DIF:    Cognitive Level: Understand          REF:   p. 21              TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse is developing a plan of care for a Hispanic client who just delivered a newborn. Which cultural variation is most important to include in the care plan?
a. Breastfeeding is encouraged immediately after birth.
b. Male infants are typically circumcised.
c. Maternal grandmother participates in the care of the mother and her infant.
d. Bathing is encouraged immediately after delivery.

 

 

ANS:  C

In the Hispanic family, the expectant mother is strongly influenced by her mother or mother-in-law. Breastfeeding is often delayed until the third postpartum day. Hispanic male infants are not usually circumcised. Bathing after delivery is most often delayed.

 

DIF:    Cognitive Level: Apply                  REF:   p. 26              TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which health care service represents a primary level of prevention?
a. Immunizations
b. Breast self-examination (BSE)
c. Home care for high-risk pregnancies
d. Blood pressure screening

 

 

ANS:  A

Primary prevention involves health promotion and disease prevention activities to reduce the occurrence of illness and enhance the general health and quality of life. This level of care includes, for example, immunizations, using infant car seats, and providing health education to prevent tobacco use. BSE is an example of secondary prevention that involves early detection of health problems. Home care for a high-risk pregnancy is an example of tertiary prevention. This level of care follows the occurrence of a defect or disability. Blood pressure screening is an example of secondary prevention and is a screening tool for early detection of a health care problem.

 

DIF:    Cognitive Level: Understand          REF:   p. 34

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the primary difference between hospital care and home health care?
a. Home care is routinely and continuously delivered by professional staff.
b. Home care is delivered on an intermittent basis by professional staff.
c. Home care is delivered for emergency conditions.
d. Home care is not available 24 hours a day.

 

 

ANS:  B

Home care is generally delivered on an intermittent basis by professional staff members. The primary difference between health care in a hospital and home care is the absence of the continuous presence of professional health care providers in a client’s home. In a true emergency, the client should be directed to call 9-1-1 or to report to the nearest hospital’s emergency department. Generally, home health care entails intermittent care by a professional who visits the client’s home for a particular reason and provides on-site care for periods shorter than 4 hours at a time.

 

DIF:    Cognitive Level: Understand          REF:   pp. 34-35

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. To provide culturally competent care to an Asian-American family, which question should the nurse include during the assessment interview?
a. “Do you prefer hot or cold beverages?”
b. “Do you want some milk to drink?”
c. “Do you want music playing while you are in labor?”
d. “Do you have a name selected for the baby?”

 

 

ANS:  A

Asian-Americans often prefer warm beverages. Milk is usually excluded from the diet of this population. Asian-American women typically labor in a quiet environment. Delaying naming the child is not uncommon for Asian-American families.

 

DIF:    Cognitive Level: Apply                  REF:   p. 27

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

  1. The woman’s family members are present when the nurse arrives for a postpartum and newborn visit. What should the nurse do?
a. Observe the family members’ interactions with the newborn and one another.
b. Ask the woman to meet with her and the baby alone.
c. Perform a brief assessment on all family members who are present.
d. Reschedule the visit for another time so that the mother and infant can be privately assessed.

 

 

ANS:  A

The nurse should introduce her or himself to the client and to the other family members who are present. Family members in the home may be providing care and assistance to the mother and infant. However, this care may not be based on sound health practices. Nurses should take the opportunity to dispel myths while family members are present. The responsibility of the home care maternal-child nurse is to provide care to the new postpartum mother and to her infant, not to all family members. The nurse can politely ask about the other people in the home and their relationships with the mother. Unless an indication is given that the woman would prefer privacy, the visit may continue.

 

DIF:    Cognitive Level: Analyze               REF:   p. 35

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. What is a limitation of a home postpartum visit?
a. Distractions limit the nurse’s ability to teach.
b. Identified problems cannot be resolved in the home setting.
c. Necessary items for infant care are not available.
d. Home visits to different families may require the nurse to travel a great distance.

 

 

ANS:  D

One limitation of home health visits is the distance the nurse must travel between clients. Driving directions should be obtained by telephone before the visit. The home care nurse is accustomed to distractions but may request that the television be turned off so that attention can be focused on the client and her family. Problems cannot always be resolved; however, appropriate referrals may be arranged by the nurse. The nurse is required to bring any necessary equipment, such as a thermometer, baby scale, or laptop computer, for documentation.

 

DIF:    Cognitive Level: Understand          REF:   p. 35              TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. During the childbearing experience, which behavior might the nurse expect from an African-American client?
a. Seeking prenatal care early in her pregnancy
b. Avoiding self-treatment of pregnancy-related discomfort
c. Requesting liver in the postpartum period to prevent anemia
d. Arriving at the hospital in advanced labor

 

 

ANS:  D

African-American women often arrive at the hospital in far-advanced labor and may view pregnancy as a state of wellness, which is often the reason for the delay in seeking prenatal care. African-American women practice many self-treatment options for various discomforts of pregnancy. African-American women may also request liver in the postpartum period, which is based on a belief that liver has a higher blood content.

 

DIF:    Cognitive Level: Understand          REF:   p. 26

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which resource best describes a health care service representing the tertiary level of prevention?
a. Stress management seminars
b. Childbirth education classes for single parents
c. BSE pamphlet and teaching
d. Premenstrual syndrome (PMS) support group

 

 

ANS:  D

A PMS support group is an example of tertiary prevention, which follows the occurrence of a defect or disability (e.g., PMS). Stress management seminars are a primary prevention technique for preventing health care issues associated with stress. Childbirth education is a form of primary prevention. BSE information is a form of secondary prevention, which is aimed toward early detection of health problems.

 

DIF:    Cognitive Level: Understand          REF:   p. 28

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. When the services of an interpreter are needed, which is the most important factor for the nurse to consider?
a. Using a family member who is fluent in both languages
b. Using an interpreter who is certified, and documenting the person’s name in the nursing notes
c. Directing questions only to the interpreter
d. Using an interpreter only in an emergency

 

 

ANS:  B

Using a certified interpreter ensures that the standards of care are met and that the information exchanged is reliable and unaltered. The name of the interpreter should be documented for legal purposes. Asking a family member to interpret may not be appropriate, although many health care personnel must adopt this approach in an emergency. Furthermore, most states require that certified interpreters be used when possible. When using an interpreter, the nurse should direct questions to the client. The interpreter is simply a means by which the nurse communicates with the client. Every attempt should be made to contact an interpreter whenever one is needed. During an emergency, health care workers often rely on information interpreted by family members. This information may be private and should be protected under the rules established by the Health Insurance Portability and Accountability Act (HIPAA). Furthermore, family members may skew information or may not be able to interpret the exact information the nurse is trying to obtain.

 

DIF:    Cognitive Level: Apply                  REF:   pp. 24, 25

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Which traditional family structure is decreasing in numbers and attributable to societal changes?
a. Extended family
b. Binuclear family
c. Nuclear family
d. Blended family

 

 

ANS:  C

The nuclear family has long represented the traditional American family in which husband, wife, and children live as an independent unit. As a result of rapid changes in society, this number is steadily decreasing as other family configurations are socially recognized. Extended families involve additional blood relatives other than the parents. A binuclear family involves two households. A blended family is reconstructed after divorce and involves the merger of two families.

 

DIF:    Cognitive Level: Understand          REF:   p. 18

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which statement regarding the Family Systems Theory is inaccurate?
a. Family system is part of a larger suprasystem.
b. Family, as a whole, is equal to the sum of the individual members.
c. Changes in one family member affect all family members.
d. Family is able to create a balance between change and stability.

 

 

ANS:  B

A family, as a whole, is greater than the sum of its individual members. The other statements are accurate and can be attributed to the Family Systems Theory.

 

DIF:    Cognitive Level: Understand          REF:   p. 21

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which pictorial tool can assist the nurse in assessing the aspects of family life related to health care?
a. Genogram
b. Ecomap
c. Life-cycle model
d. Human development wheel

 

 

ANS:  A

A genogram depicts the relationships of the family members over generations. An ecomap is a graphic portrayal of the social relationships of the woman and her family. The life-cycle model, in no way, illustrates a family genogram; rather, it focuses on the stages that a person reaches throughout life. The human development wheel describes various stages of growth and development rather than the family members’ relationships to each other.

 

DIF:    Cognitive Level: Remember           REF:   pp. 20-21

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. When attempting to communicate with a client who speaks a different language, which action is the most appropriate?
a. Promptly and positively respond to project authority.
b. Never use a family member as an interpreter.
c. Talk to the interpreter to avoid confusing the client.
d. Provide as much privacy as possible.

 

 

ANS:  D

Providing privacy creates an atmosphere of respect and puts the client at ease. The nurse should not rush to judgment and should ensure she or he clearly understands the client’s message. In crisis situations, the nurse may need to use a family member or neighbor as a translator. The nurse should speak directly to the client to create an atmosphere of respect.

 

DIF:    Cognitive Level: Apply                  REF:   p. 24

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. The secondary level of prevention is best illustrated by which example?
a. Approved infant car seats
b. BSE
c. Immunizations
d. Support groups for parents of children with Down syndrome

 

 

ANS:  B

Infant car seats are an example of primary prevention. BSE is an example of the secondary level of prevention, which includes health-screening measures for early detection of health problems. Immunizations are an example of the primary level of prevention. Support groups are an example of tertiary prevention, which follows the occurrence of a defect or disability (e.g., Down syndrome).

 

DIF:    Cognitive Level: Understand          REF:   p. 28              TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which key point is important for the nurse to understand regarding the perinatal continuum of care?
a. Begins with conception and ends with the birth
b. Begins with family planning and continues until the infant is 1 year old
c. Begins with prenatal care and continues until the newborn is 24 weeks old
d. Refers to home care only

 

 

ANS:  B

The perinatal continuum of care begins with family planning and continues until the infant is 1 year old. It takes place both at home and in health care facilities. The perinatal continuum does not end with the birth. The perinatal continuum begins before conception and continues after the birth. Home care is one delivery component; health care facilities are another.

 

DIF:    Cognitive Level: Remember           REF:   p. 17              TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What information should the nurse be aware of regarding telephonic nursing care such as warm lines?
a. Were developed as a reaction to impersonal telephonic nursing care
b. Were set up to take complaints concerning health maintenance organizations (HMOs)
c. Are the second option when 9-1-1 hotlines are busy
d. Refer to community service telephone lines designed to provide new parents with encouragement and basic information

 

 

ANS:  D

Warm lines are one aspect of telephonic nursing care specifically designed to provide new parents with encouragement and basic information. Warm lines and similar services sometimes are set up by HMOs to provide new parents with encouragement and basic information. The name, warm lines, may have been suggested by the term hotlines, but these are not emergency numbers but are designed to provide new parents with encouragement and basic information.

 

DIF:    Cognitive Level: Remember           REF:   p. 34

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. When weighing the advantages and disadvantages of planning home care for perinatal services, what information should the nurse use in making the decision?
a. Home care for perinatal services is more dangerous for vulnerable neonates at risk of acquiring an infection from the nurse.
b. Home care for perinatal services is more cost-effective for the nurse than office visits.
c. Home care for perinatal services allows the nurse to interact with and include family members in teaching.
d. Home care for perinatal services is made possible by the ready supply of nurses with expertise in maternity care.

 

 

ANS:  C

Treating the whole family is an advantage of home care. Forcing neonates out in inclement weather and in public is more risky. Office visits are more cost-effective for the providers such as nurses because less travel time is involved. Unfortunately, home care options are limited by the lack of nurses with expertise in maternity care.

 

DIF:    Cognitive Level: Apply                  REF:   p. 35

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. In what form do families tend to be the most socially vulnerable?
a. Married-blended family
b. Extended family
c. Nuclear family
d. Single-parent family

 

 

ANS:  D

The single-parent family tends to be economically and socially vulnerable, creating an unstable and deprived environment for the growth potential of children. The married-blended family, the extended family, and the nuclear family are not the most socially vulnerable.

 

DIF:    Cognitive Level: Understand          REF:   p. 19              TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. While working in the prenatal clinic, nurses care for a very diverse group of clients. Which cultural factor related to health is most likely to drive acceptance of planned interventions?
a. Educational achievement
b. Income level
c. Subcultural group
d. Individual beliefs

 

 

ANS:  D

The client’s beliefs are ultimately the key to the acceptance of health care interventions. However, these beliefs may be influenced by factors such as educational level, income level, and ethnic background. Educational achievement, income level, and being part of a subcultural group all are important factors. However, the nurse must understand that a woman’s concerns from her own point of view will have the most influence on her compliance and acceptance of health care interventions.

 

DIF:    Cognitive Level: Apply                  REF:   pp. 21-22       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A client’s household consists of her husband, his mother, and another child. To which family configuration does this client belong?
a. Multigenerational family
b. Single-parent family
c. Married-blended family
d. Nuclear family

 

 

ANS:  A

A multigenerational family includes three or more generations living together. Both parents and a grandparent are living in this extended family. Single-parent families comprise an unmarried biologic or adoptive parent who may or may not be living with other adults. Married-blended families refer to those who are reconstructed after divorce. A nuclear family comprises male and female partners and their children living together as an independent unit.

 

DIF:    Cognitive Level: Apply                  REF:   p. 19

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which term is an accurate description of the process by which people retain some of their own culture while adopting the practices of the dominant society?
a. Acculturation
b. Assimilation
c. Ethnocentrism
d. Cultural relativism

 

 

ANS:  A

Acculturation is the process by which people retain some of their own culture while adopting the practices of the dominant society. This process takes place over the course of generations. Assimilation is a loss of cultural identity. Ethnocentrism is the belief in the superiority of one’s own culture over the cultures of others. Cultural relativism recognizes the roles of different cultures.

 

DIF:    Cognitive Level: Understand          REF:   pp. 22-23       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. In which culture is the father more likely to be expected to participate in the labor and delivery?
a. Asian-American
b. African-American
c. European-American
d. Hispanic

 

 

ANS:  C

European-Americans expect the father to take a more active role in the labor and delivery of a newborn than the other cultures.

 

DIF:    Cognitive Level: Understand          REF:   p. 27

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Which statement about the development of cultural competence is inaccurate?
a. Local health care workers and community advocates can help extend health care to underserved populations.
b. Nursing care is delivered in the context of the client’s culture but not in the context of the nurse’s culture.
c. Nurses must develop an awareness of and a sensitivity to various cultures.
d. Culture’s economic, religious, and political structures influence practices that affect childbearing.

 

 

ANS:  B

Although the cultural context of the nurse affects the delivery of nursing care and is very important, the work of local health care workers and community advocates, developing sensitivity to various cultures, and the impact of economic, religious, and political structures are all parts of cultural competence.

 

DIF:    Cognitive Level: Understand          REF:   pp. 27-28       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which statement accurately describes the walking survey as a data collection tool?
a. The walking survey determines how much exercise an expectant mother has been getting, to help her make health care decisions.
b. The walking survey usually takes place on the maternity ward but can be expanded to other areas of the hospital.
c. The walking survey is a method of observing the resources and health-related environment of the community.
d. The walking survey is performed by government census takers as part of their canvas.

 

 

ANS:  C

The walking survey is a valuable tool for the nurses in the community and has nothing to do with exercise. It is an observational method used to assess the health environment of the community. A walking survey takes place in the community, not the maternity ward, and is not part of the census; it is conducted by nurses in the community.

 

DIF:    Cognitive Level: Remember           REF:   p. 30

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A Native-American woman gave birth to a baby girl 12 hours ago. The nurse notes that the woman keeps her baby in the bassinet except for bottle feeding and states that she will wait until she gets home to begin breastfeeding. The nurse recognizes that this behavior is most likely a reflection of what?
a. Delayed attachment
b. Embarrassment
c. Disappointment in the sex of the baby
d. Belief that babies should not be fed colostrum

 

 

ANS:  D

Native Americans often use cradle boards and often avoid handling their newborn. They also believe that the infant should not be fed colostrum. Delayed attachment is a developmental concern, not a cultural belief. Embarrassment is not likely the cause for a delay in the initiation of breastfeeding and should be explored further by the nurse. The mother may voice her disappointment that the infant is a girl; however, this would rarely cause her to delay breastfeeding and would exhibit itself in other ways.

 

DIF:    Cognitive Level: Understand          REF:   p. 27

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. While completing an assessment of a homeless woman, the nurse should be aware of which of the following ailments this client is at a higher risk to develop? (Select all that apply.)
a. Infectious diseases
b. Chronic illness
c. Anemia
d. Hyperthermia
e. Substance abuse

 

 

ANS:  A, B, C, E

Poor living conditions contribute to higher rates of infectious disease. Many homeless individuals engage in sexual favors, which may expose them to sexually transmitted infections (STIs). Poor nutrition can lead to anemia. Lifestyle factors also contribute to chronic illness. Exposure to cold temperatures and harsh environmental surroundings may lead to hypothermia. Many homeless people turn to alcohol and other substances as coping mechanisms.

 

DIF:    Cognitive Level: Analyze               REF:   pp. 32-33

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Safe and Effective Care Environment

 

Chapter 12: Conception and Fetal Development

Lowdermilk: Maternity & Women’s Health Care, 11th Edition

 

MULTIPLE CHOICE

 

  1. A newly married couple plans to use the natural family planning method of contraception. Understanding how long an ovum can live after ovulation is important to them. The nurse knows that his or her teaching was effective when the couple responds that an ovum is considered fertile for which period of time?
a. 6 to 8 hours
b. 24 hours
c. 2 to 3 days
d. 1 week

 

 

ANS:  B

Most ova remain fertile for approximately 24 hours after ovulation, much longer than 6 to 8 hours. However, ova do not remain fertile for 2 to 3 days or are viable for 1 week. If unfertilized by a sperm after 24 hours, the ovum degenerates and is reabsorbed.

 

DIF:    Cognitive Level: Understand          REF:   p. 266            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What kind of fetal anomalies are most often associated with oligohydramnios?
a. Renal
b. Cardiac
c. Gastrointestinal
d. Neurologic

 

 

ANS:  A

An amniotic fluid volume of less than 300 ml (oligohydramnios) is often associated with fetal renal anomalies. The amniotic fluid volume has no bearing on the fetal cardiovascular system. Gastrointestinal anomalies are associated with hydramnios or an amniotic fluid volume greater than 2 L. The amniotic fluid volume has no bearing on the fetal neurologic system.

 

DIF:    Cognitive Level: Remember           REF:   p. 276

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A pregnant woman at 25 weeks of gestation tells the nurse that she dropped a pan last week and her baby jumped at the noise. Which response by the nurse is most accurate?
a. “That must have been a coincidence; babies can’t respond like that.”
b. “The fetus is demonstrating the aural reflex.”
c. “Babies respond to sound starting at approximately 24 weeks of gestation.”
d. “Let me know if it happens again; we need to report that to your midwife.”

 

 

ANS:  C

Babies respond to external sound starting at approximately 24 weeks of gestation. Acoustic stimulations can evoke a fetal heart rate response. There is no such thing as an aural reflex. The last statement is inappropriate and may cause undue psychologic alarm to the client.

 

DIF:    Cognitive Level: Apply                  REF:   p. 276            TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. At a routine prenatal visit, the nurse explains the development of the fetus to her client. At approximately ____ weeks of gestation, lecithin is forming on the alveolar surfaces, the eyelids open, and the fetus measures approximately 27 cm crown to rump and weighs approximately 1110 g. The client is how many weeks of gestation at today’s visit?
a. 20
b. 24
c. 28
d. 30

 

 

ANS:  C

These milestones in human development occur at 28 weeks of gestation. These milestones have not occurred by 20 or 24 weeks of gestation but have been reached before 30 weeks of gestation.

 

DIF:    Cognitive Level: Understand          REF:   p. 280

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which statement regarding the structure and function of the placenta is correct?
a. Produces nutrients for fetal nutrition
b. Secretes both estrogen and progesterone
c. Forms a protective, impenetrable barrier to microorganisms such as bacteria and viruses
d. Excretes prolactin and insulin

 

 

ANS:  B

As one of its early functions, the placenta acts as an endocrine gland, producing four hormones necessary to maintain the pregnancy and to support the embryo or fetus: human chorionic gonadotropin (hCG), human placental lactogen (hPL), estrogen, and progesterone. The placenta does not produce nutrients. It functions as a means of metabolic exchange between the maternal and fetal blood supplies. Many bacteria and viruses can cross the placental membrane.

 

DIF:    Cognitive Level: Understand          REF:   p. 271

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A woman in labor passes some thick meconium as her amniotic fluid ruptures. The client asks the nurse where the baby makes the meconium. What is the correct response by the nurse?
a. Fetal intestines
b. Fetal kidneys
c. Amniotic fluid
d. Placenta

 

 

ANS:  A

As the fetus nears term, fetal waste products accumulate in the intestines as dark green-to-black, tarry meconium. Meconium is not produced by the fetal kidneys nor should it be present in the amniotic fluid, which may be an indication of fetal compromise. The placenta does not produce meconium.

 

DIF:    Cognitive Level: Apply                  REF:   p. 275

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A woman asks the nurse, “What protects my baby’s umbilical cord from being squashed while the baby’s inside of me?” What is the nurse’s best response?
a. “Your baby’s umbilical cord is surrounded by connective tissue called Wharton’s jelly, which prevents compression of the blood vessels.”
b. “Your baby’s umbilical cord floats around in blood and amniotic fluid.”
c. “You don’t need to be worrying about things like that.”
d. “The umbilical cord is a group of blood vessels that are very well protected by the placenta.”

 

 

ANS:  A

Explaining the structure and function of the umbilical cord is the most appropriate response. Connective tissue called Wharton’s jelly surrounds the umbilical cord, prevents compression of the blood vessels, and ensures continued nourishment of the embryo or fetus. The umbilical cord does not float around in blood or fluid. Telling the client not to worry negates her need for information and discounts her feelings. The placenta does not protect the umbilical cord.

 

DIF:    Cognitive Level: Apply                  REF:   p. 270            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which structure is responsible for oxygen and carbon dioxide transport to and from the maternal bloodstream?
a. Decidua basalis
b. Blastocyst
c. Germ layer
d. Chorionic villi

 

 

ANS:  D

Chorionic villi are fingerlike projections that develop out of the trophoblast and extend into the blood-filled spaces of the endometrium. The villi obtain oxygen and nutrients from the maternal bloodstream and dispose carbon dioxide and waste products into the maternal blood. The decidua basalis is the portion of the decidua (endometrium) under the blastocyst where the villi attach. The blastocyst is the embryonic development stage after the morula; implantation occurs at this stage. The germ layer is a layer of the blastocyst.

 

DIF:    Cognitive Level: Understand          REF:   p. 270

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A woman who is 8 months pregnant asks the nurse, “Does my baby have any antibodies to fight infection?” What is the most appropriate response by the nurse?
a. “Your baby has all the immunoglobulins necessary: immunoglobulin G (IgG), immunoglobulin M (IgM), and immunoglobulin A (IgA).”
b. “Your baby won’t receive any antibodies until he is born and you breastfeed him.”
c. “Your baby does not have any antibodies to fight infection.”
d. “Your baby has IgG and IgM.”

 

 

ANS:  D

During the third trimester, IgG is the only immunoglobulin that crosses the placenta; it provides passive acquired immunity to specific bacterial toxins. However, the fetus produces IgM by the end of the first trimester. IgA immunoglobulins are not produced by the baby. Therefore, by the third trimester, the fetus has both IgG and IgM. Breastfeeding supplies the newborn infant with IgA.

 

DIF:    Cognitive Level: Apply                  REF:   p. 277            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The measurement of lecithin in relation to sphingomyelin (lecithin/sphingomyelin [L/S] ratio) is used to determine fetal lung maturity. Which ratio reflects fetal maturity of the lungs?
a. 1.4:1
b. 1.8:1
c. 2:1
d. 1:1

 

 

ANS:  C

The L/S ratio indicates a 2:1 ratio of lecithin to sphingomyelin, which is an indicator of fetal lung maturity and occurs at approximately the middle of the third trimester. L/S ratios of 1.4:1, 1.8:1, and 1:1 each indicate immaturity of the fetal lungs.

 

DIF:    Cognitive Level: Remember           REF:   p. 275            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A client arrives for her initial prenatal examination. This is her first child. She asks the nurse, “How does my baby get air inside my uterus?” What is the correct response by the nurse?
a. “The baby’s lungs work in utero to exchange oxygen and carbon dioxide.”
b. “The baby absorbs oxygen from your blood system.”
c. “The placenta provides oxygen to the baby and excretes carbon dioxide into your bloodstream.”
d. “The placenta delivers oxygen-rich blood through the umbilical artery to the baby’s abdomen.”

 

 

ANS:  C

The placenta delivers oxygen-rich blood through the umbilical vein, not the artery, to the fetus and excretes carbon dioxide into the maternal bloodstream. The fetal lungs do not function as respiratory gas exchange in utero. The baby does not simply absorb oxygen from a woman’s blood system; rather, blood and gas transport occur through the placenta.

 

DIF:    Cognitive Level: Apply                  REF:   p. 271            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the most basic information that a nurse should be able to share with a client who asks about the process of conception?
a. Ova are considered fertile 48 to 72 hours after ovulation.
b. Sperm remain viable in the woman’s reproductive system for an average of 12 to 24 hours.
c. Conception is achieved when a sperm successfully penetrates the membrane surrounding the ovum.
d. Implantation in the endometrium occurs 6 to 10 days after conception.

 

 

ANS:  D

After implantation, the endometrium is called the decidua. Ova are considered fertile for approximately 24 hours after ovulation. Sperm remain viable in the woman’s reproductive system for an average of 2 to 3 days. Penetration of the ovum by the sperm is called fertilization. Conception occurs when the zygote, the first cell of the new individual, is formed.

 

DIF:    Cognitive Level: Remember           REF:   p. 267

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The maternity nurse is cognizant of what important structure and function of the placenta?
a. As the placenta widens, it gradually thins to allow easier passage of air and nutrients.
b. As one of its early functions, the placenta acts as an endocrine gland.
c. The placenta is able to keep out most potentially toxic substances, such as cigarette smoke, to which the mother is exposed.
d. Optimal blood circulation is achieved through the placenta when the woman is lying on her back or standing.

 

 

ANS:  B

The placenta produces four hormones necessary to maintain the pregnancy: hCG, hPL, estrogen, and progesterone. The placenta widens until 20 weeks of gestation and continues to grow thicker. Toxic substances such as nicotine and carbon monoxide readily cross the placenta into the fetus. Optimal circulation occurs when the woman is lying on her side.

 

DIF:    Cognitive Level: Understand          REF:   p. 271

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which statement regarding the development of the respiratory system is a high priority for the nurse to understand?
a. The respiratory system does not begin developing until after the embryonic stage.
b. The infant’s lungs are considered mature when the L/S ratio is 1:1, at approximately 32 weeks of gestation.
c. Maternal hypertension can reduce maternal-placental blood flow, accelerating lung maturity.
d. Fetal respiratory movements are not visible on ultrasound scans until at least 16 weeks of gestation.

 

 

ANS:  C

A reduction in placental blood flow stresses the fetus, increases blood levels of corticosteroids, and thus accelerates lung maturity. The development of the respiratory system begins during the embryonic phase and continues into childhood. The infant’s lungs are considered mature when the L/S ratio is 2:1, at approximately 35 weeks of gestation. Lung movements have been visualized on ultrasound scans at 11 weeks of gestation.

 

DIF:    Cognitive Level: Understand          REF:   p. 275            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The various systems and organs of the fetus develop at different stages. Which statement is most accurate?
a. Cardiovascular system is the first organ system to function in the developing human.
b. Hematopoiesis originating in the yolk sac begins in the liver at 10 weeks of gestation.
c. Body changes from straight to C-shape occurs at 8 weeks of gestation.
d. Gastrointestinal system is mature at 32 weeks of gestation.

 

 

ANS:  A

The heart is developmentally complete by the end of the embryonic stage. Hematopoiesis begins in the liver during the sixth week. The body becomes C-shaped at 21 weeks of gestation. The gastrointestinal system is complete at 36 weeks of gestation.

 

DIF:    Cognitive Level: Remember           REF:   p. 273

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which statement concerning neurologic and sensory development in the fetus is correct?
a. Brain waves have been recorded on an electroencephalogram as early as the end of the first trimester (12 weeks of gestation).
b. Fetuses respond to sound by 24 weeks of gestation and can be soothed by the sound of the mother’s voice.
c. Eyes are first receptive to light at 34 to 36 weeks of gestation.
d. At term, the fetal brain is at least one third the size of an adult brain.

 

 

ANS:  B

Hearing develops early and is fully developed at birth. Brain waves have been recorded at week 8. Eyes are receptive to light at 28 weeks of gestation. The fetal brain is approximately one fourth the size of an adult brain.

 

DIF:    Cognitive Level: Remember           REF:   p. 276            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A woman’s cousin gave birth to an infant with a congenital heart anomaly. The woman asks the nurse when such anomalies occur during development. Which response by the nurse is most accurate?
a. “We don’t really know when such defects occur.”
b. “It depends on what caused the defect.”
c. “Defects occur between the third and fifth weeks of development.”
d. “They usually occur in the first 2 weeks of development.”

 

 

ANS:  C

The cardiovascular system is the first organ system to function in the developing human. Blood vessel and blood formation begins in the third week, and the heart is developmentally complete in the fifth week. “We don’t really know when such defects occur” is an inaccurate statement. Regardless of the cause, the heart is vulnerable during its period of development—in the third to fifth weeks; therefore, the statement, “They usually occur in the first 2 weeks of development” is inaccurate.

 

DIF:    Cognitive Level: Apply                  REF:   p. 273            TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which information regarding amniotic fluid is important for the nurse to understand?
a. Amniotic fluid serves as a source of oral fluid and a repository for waste from the fetus.
b. Volume of the amniotic fluid remains approximately the same throughout the term of a healthy pregnancy.
c. The study of fetal cells in amniotic fluid yields little information.
d. A volume of more than 2 L of amniotic fluid is associated with fetal renal abnormalities.

 

 

ANS:  A

Amniotic fluid serves as a source of oral fluid, serves as a repository for waste from the fetus, cushions the fetus, and helps maintain a constant body temperature. The volume of amniotic fluid constantly changes. The study of amniotic fluid yields information regarding the sex of the fetus and the number of chromosomes. Too much amniotic fluid (hydramnios) is associated with gastrointestinal and other abnormalities.

 

DIF:    Cognitive Level: Understand          REF:   p. 270

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. An expectant couple attending childbirth classes have questions regarding multiple births since twins “run in the family.” What information regarding multiple births is important for the nurse to share?
a. Twinning and other multiple births are increasing because of the use of fertility drugs and delayed childbearing.
b. Dizygotic twins (two fertilized ova) have the potential to be conjoined twins.
c. Identical twins are more common in Caucasian families.
d. Fraternal twins are the same gender, usually male.

 

 

ANS:  A

If the parents-to-be are older and have taken fertility drugs, then they would be very interested to know about twinning and other multiple births. Conjoined twins are monozygotic; that is, they are from a single fertilized ovum in which division occurred very late. Identical twins show no racial or ethnic preference, and fraternal twins are more common among African-American women. Fraternal twins can be different genders or the same gender, and identical twins are the same gender.

 

DIF:    Cognitive Level: Understand          REF:   p. 277            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse caring for a pregnant client is evaluating his or her health teaching regarding fetal circulation. Which statement from the client reassures the nurse that his or her teaching has been effective?
a. “Optimal fetal circulation is achieved when I am in the side-lying position.”
b. “Optimal fetal circulation is achieved when I am on my back with a pillow under my knees.”
c. “Optimal fetal circulation is achieved when the head of the bed is elevated.”
d. “Optimal fetal circulation is achieved when I am on my abdomen.”

 

 

ANS:  A

Optimal circulation is achieved when the woman is lying at rest on her side. Decreased uterine circulation may lead to intrauterine growth restriction. Previously, it was believed that the left lateral position promoted maternal cardiac output, enhancing blood flow to the fetus. However, it is now known that the side-lying position enhances uteroplacental blood flow. If a woman lies on her back with the pressure of the uterus compressing the vena cava, then blood return to the right atrium is diminished. Although having the head of the bed elevated is recommended and ideal for later in pregnancy, the woman still must maintain a lateral tilt to the pelvis to avoid compressing the vena cava. Many women find lying on their abdomen uncomfortable as pregnancy advances. Side-lying is the ideal position to promote blood flow to the fetus.

 

DIF:    Cognitive Level: Analyze               REF:   p. 273            TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Some of the embryo’s intestines remain within the umbilical cord during the embryonic period. What is the rationale for this development of the gastrointestinal system?
a. Umbilical cord is much larger at this time than it will be at the end of pregnancy.
b. Intestines begin their development within the umbilical cord.
c. Nutrient content of the blood is higher in this location.
d. Abdomen is too small to contain all the organs while they are developing.

 

 

ANS:  D

The abdominal contents grow more rapidly than the abdominal cavity; therefore, part of their development takes place in the umbilical cord. By 10 weeks of gestation, the abdomen is large enough to contain them. Intestines begin their development within the umbilical cord but only because the liver and kidneys occupy most of the abdominal cavity. Blood supply is adequate in all areas.

 

DIF:    Cognitive Level: Understand          REF:   p. 275

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A woman is 15 weeks pregnant with her first baby. She asks how long it will be before she feels the baby move. What is the nurse’s best answer?
a. “You should have felt the baby move by now.”
b. “Within the next month, you should start to feel fluttering sensations.”
c. “The baby is moving; however, you can’t feel it yet.”
d. “Some babies are quiet, and you don’t feel them move.”

 

 

ANS:  B

Maternal perception of fetal movement usually begins 16 to 20 weeks after conception. Because this is her first pregnancy, movement is felt toward the later part of the 16- to 20-week time period. Stating, “you should have felt the baby move by now” is incorrect and may be an alarming statement to the client. Fetal movement should be felt by 16 to 20 weeks. If movement is not felt by the end of that time, then further assessment is necessary.

 

DIF:    Cognitive Level: Comprehend        REF:   p. 277

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A new mother asks the nurse about the “white substance” covering her infant. How should the nurse explain the purpose of vernix caseosa?
a. Vernix caseosa protects the fetal skin from the amniotic fluid.
b. Vernix caseosa promotes the normal development of the peripheral nervous system.
c. Vernix caseosa allows the transport of oxygen and nutrients across the amnion.
d. Vernix caseosa regulates fetal temperature.

 

 

ANS:  A

Prolonged exposure to the amniotic fluid during the fetal period could result in the breakdown of the skin without the protection of the vernix caseosa. Normal development of the peripheral nervous system was dependent on nutritional intake of the mother. The amnion was the inner membrane that surrounded the fetus and was not involved in the oxygen and nutrient exchange. The amniotic fluid helped maintain fetal temperature.

 

DIF:    Cognitive Level: Remember           REF:   p. 277

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A woman who is 16 weeks pregnant asks the nurse, “Is it possible to tell by ultrasound if the baby is a boy or girl yet?” What is the best answer?
a. “A baby’s sex is determined as soon as conception occurs.”
b. “The baby has developed enough to enable us to determine the sex by examining the genitals through an ultrasound scan.”
c. “Boys and girls look alike until approximately 20 weeks after conception, and then they begin to look different.”
d. “It might be possible to determine your baby’s sex, but the external organs look very similar right now.”

 

 

ANS:  B

Although gender is determined at conception, the external genitalia of males and females look similar through the ninth week. By the twelfth week, the external genitalia are distinguishable as male or female.

 

DIF:    Cognitive Level: Understand          REF:   pp. 276, 278

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which development related to the integumentary system is correct?
a. Very fine hairs called lanugo appear at 12 weeks of gestation.
b. Eyelashes, eyebrows, and scalp hair appear at 28 weeks of gestation.
c. Fingernails and toenails develop at 28 weeks of gestation.
d. By 32 weeks, scalp hair becomes apparent.

 

 

ANS:  A

Very fine hairs, called lanugo appear first at 12 weeks of gestational age on the fetus’ eyebrows and upper lip. By 20 weeks of gestation, lanugo covers the entire body. By 20 weeks of gestation the eyelashes, eyebrows, and scalp hair also begin to grow. By 28 weeks of gestation, the scalp hair is longer than these fine hairs, which is thin and may disappear by term. Fingernails and toenails develop from thickened epidermis, beginning during the 10th week. Fingernails reach the fingertips at 32 weeks of gestation, and the toenails reach the toe tips at 36 weeks of gestation.

 

DIF:    Cognitive Level: Remember           REF:   p. 277

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The pancreas forms in the foregut during the 5th to 8th week of gestation. A client with poorly controlled gestational diabetes asks the nurse what the effects of her condition will be on the fetus. What is the best response by the nurse? Poorly controlled maternal gestational diabetes will:
a. produce fetal hypoglycemia.
b. result in a macrocosmic fetus.
c. result in a microcosmic fetus.
d. enhance lung maturation.

 

 

ANS:  B

Insulin is produced by week 20 of gestation. In the fetus of a mother with uncontrolled diabetes, maternal hypoglycemia produces fetal hypoglycemia and macrocosmia results. Hyperinsulinemia blocks lung maturation, placing the neonate at risk for respiratory distress.

 

DIF:    Cognitive Level: Understand          REF:   p. 276

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. Congenital disorders refer to those conditions that are present at birth. These disorders may be inherited and caused by environmental factors or maternal malnutrition. Toxic exposures have the greatest effect on development between 15 and 60 days of gestation. For the nurse to be able to conduct a complete assessment of the newly pregnant client, he or she should be knowledgeable regarding known human teratogens. Which substances might be considered a teratogen? (Select all that apply.)
a. Cytomegalovirus (CMV)
b. Ionizing radiation
c. Hypothermia
d. Carbamazepine
e. Lead

 

 

ANS:  A, B, D, E

Exposure to radiation and a number of infections may result in profound congenital deformities. These include but are not limited to varicella, rubella, syphilis, parvovirus, CMV, and toxoplasmosis. Certain maternal conditions such as diabetes and phenylketonuria (PKU) may also affect organs and other parts of the embryo during this developmental period. Drugs such as antiseizure medications (e.g., carbamazepine) and some antibiotics, as well as chemicals including lead, mercury, tobacco, and alcohol, may also result in structural and functional abnormalities.

 

DIF:    Cognitive Level: Remember           REF:   p. 273

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Relating to the fetal circulatory system, which special characteristics allow the fetus to obtain sufficient oxygen from the maternal blood? (Select all that apply.)
a. Fetal hemoglobin (Hb) carries 20% to 30% more oxygen than maternal Hb.
b. Fetal Hb carries 40% to 50% more oxygen than maternal Hb.
c. Hb concentration is 50% higher than that of the mother.
d. Fetal heart rate is 110 to 160 beats per minute.
e. Fetal heart rate is 160 to 200 beats per minute.

 

 

ANS:  A, C, D

The following three special characteristics enable the fetus to obtain sufficient oxygen from maternal blood: (1) the fetal Hb carries 20% to 30% more oxygen; (2) the concentration is 50% higher than that of the mother; and (3) the fetal heart rate is 110 to 160 beats per minute, a cardiac output that is higher than that of an adult.

 

DIF:    Cognitive Level: Understand          REF:   p. 274

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

Chapter 24: Nursing Care of the Newborn and Family

Lowdermilk: Maternity & Women’s Health Care, 11th Edition

 

MULTIPLE CHOICE

 

  1. An infant boy was delivered minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. When should the Apgar assessment be performed?
a. Only if the newborn is in obvious distress
b. Once by the obstetrician, just after the birth
c. At least twice, 1 minute and 5 minutes after birth
d. Every 15 minutes during the newborn’s first hour after birth

 

 

ANS:  C

Apgar scoring is performed at 1 minute and at 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts. The Apgar score is performed on all newborns. Apgar score can be completed by the nurse or the birth attendant. The Apgar score permits a rapid assessment of the newborn’s transition to extrauterine life. An interval of every 15 minutes is too long to wait to complete this assessment.

 

DIF:    Cognitive Level: Understand          REF:   p. 550

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A new father wants to know what medication was put into his infant’s eyes and why it is needed. How does the nurse explain the purpose of the erythromycin (Ilotycin) ophthalmic ointment?
a. Erythromycin (Ilotycin) ophthalmic ointment destroys an infectious exudate caused by Staphylococcus that could make the infant blind.
b. This ophthalmic ointment prevents gonorrheal and chlamydial infection of the infant’s eyes, potentially acquired from the birth canal.
c. Erythromycin (Ilotycin) prevents potentially harmful exudate from invading the tear ducts of the infant’s eyes, leading to dry eyes.
d. This ointment prevents the infant’s eyelids from sticking together and helps the infant see.

 

 

ANS:  B

The nurse should explain that prophylactic erythromycin ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal and chlamydial infection that potentially could have been acquired from the birth canal. This prophylactic ophthalmic ointment is not instilled to prevent dry eyes and has no bearing on vision other than to protect against infection that may lead to vision problems.

 

DIF:    Cognitive Level: Apply                  REF:   p. 568            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nurse is assessing a newborn girl who is 2 hours old. Which finding warrants a call to the health care provider?
a. Blood glucose of 45 mg/dl using a Dextrostix screening method
b. Heart rate of 160 beats per minute after vigorously crying
c. Laceration of the cheek
d. Passage of a dark black-green substance from the rectum

 

 

ANS:  C

Accidental lacerations can be inflicted by a scalpel during a cesarean birth. They are most often found on the scalp or buttocks and may require an adhesive strip for closure. Parents would be overly concerned about a laceration on the cheek. A blood glucose level of 45 mg/dl and a heart rate of 160 beats per minute after crying are both normal findings that do not warrant a call to the physician. The passage of meconium from the rectum is an expected finding in the newborn.

 

DIF:    Cognitive Level: Understand          REF:   p. 570

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

  1. What is the rationale for the administration of vitamin K to the healthy full-term newborn?
a. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient.
b. Vitamin K prevents the synthesis of prothrombin in the liver and must be administered by injection.
c. Bacteria that synthesize vitamin K are not present in the newborn’s intestinal tract.
d. The supply of vitamin K in the healthy full-term newborn is inadequate for at least 3 to 4 months and must be supplemented.

 

 

ANS:  C

Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week. The maternal diet has no bearing on the amount of vitamin K found in the newborn. Vitamin K promotes the formation of clotting factors in the liver and is used for the prevention and treatment of hemorrhagic disease in the newborn. Vitamin K is not produced in the intestinal tract of the newborn until after microorganisms are introduced. By day 8, normal newborns are able to produce their own vitamin K.

 

DIF:    Cognitive Level: Understand          REF:   pp. 568-569

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is using the New Ballard Scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks?
a. Flexed posture
b. Abundant lanugo
c. Smooth, pink skin with visible veins
d. Faint red marks on the soles of the feet

 

 

ANS:  A

Term infants typically have a flexed posture. Abundant lanugo; smooth, pink skin with visible veins; and faint red marks are usually observed on preterm infants.

 

DIF:    Cognitive Level: Understand          REF:   pp. 553, 554  TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. What is the most appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy?
a. Applying an oil-based lotion to the newborn’s skin to prevent dying and cracking
b. Limiting the newborn’s intake of milk to prevent nausea, vomiting, and diarrhea
c. Placing eye shields over the newborn’s closed eyes
d. Changing the newborn’s position every 4 hours

 

 

ANS:  C

The infant’s eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should completely cover the eyes but not occlude the nares. Lotions and ointments should not be applied to the infant because they absorb heat and can cause burns. The lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration. Therefore, adequate hydration is important for the infant. The infant should be turned every 2 hours to expose all body surfaces to the light.

 

DIF:    Cognitive Level: Apply                  REF:   p. 572            TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Early this morning, an infant boy was circumcised using the PlastiBell method. Based on the nurse’s evaluation, when will the infant be ready for discharge?
a. When the bleeding completely stops
b. When yellow exudate forms over the glans
c. When the PlastiBell plastic rim (bell) falls off
d. When the infant voids

 

 

ANS:  D

The infant should be observed for urination after the circumcision. Bleeding is a common complication after circumcision, and the nurse will check the penis for 12 hours after a circumcision to assess and provide appropriate interventions for the prevention and treatment of bleeding. Yellow exudate covers the glans penis in 24 hours after the circumcision and is part of normal healing; yellow exudate is not an infective process. The PlastiBell plastic rim (bell) remains in place for approximately a week and falls off when healing has taken place.

 

DIF:    Cognitive Level: Apply                  REF:   p. 582            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which intervention by the nurse is correct?
a. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration
b. Confirming that the newborn’s mother has been infected with the HBV
c. Assessing the dorsogluteal muscle as the preferred site for injection
d. Confirming that the newborn is at least 24 hours old

 

 

ANS:  A

The HBV vaccine should be administered in the vastus lateralis muscle at childbirth with a 25-gauge, 5/8-inch needle and is recommended for all infants. If the infant is born to an infected mother who is a chronic HBV carrier, then the hepatitis vaccine and HBV immunoglobulin should be administered within 12 hours of childbirth.

 

DIF:    Cognitive Level: Apply                  REF:   p. 579

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. This clinical finding may be indicative of what?
a. Excessive saliva is a normal finding in the newborn.
b. Excessive saliva in a neonate indicates that the infant is hungry.
c. It may indicate that the infant has a tracheoesophageal fistula or esophageal atresia.
d. Excessive saliva may indicate that the infant has a diaphragmatic hernia.

 

 

ANS:  C

The presence of excessive saliva in a neonate should alert the nurse to the possibility of a tracheoesophageal fistula or esophageal atresia. Excessive salivation may not be a normal finding and should be further assessed for the possibility that the infant has an esophageal abnormality. The hungry infant reacts by making sucking motions, rooting, or making hand-to-mouth movements. The infant with a diaphragmatic hernia exhibits severe respiratory distress.

 

DIF:    Cognitive Level: Analyze               REF:   p. 561

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

  1. A mother is changing the diaper of her newborn son and notices that his scrotum appears large and swollen. The client is concerned. What is the best response from the nurse?
a. “A large scrotum and swelling indicate a hydrocele, which is a common finding in male newborns.”
b. “I don’t know, but I’m sure it is nothing.”
c. “Your baby might have testicular cancer.”
d. “Your baby’s urine is backing up into his scrotum.”

 

 

ANS:  A

Explaining what a hydrocele is and its characteristics is the most appropriate response by the nurse. The swelling usually decreases without intervention. Telling the mother that the condition is nothing important is inappropriate and does not address the mother’s concern. Furthermore, if the nurse is unaware of any abnormal-appearing condition, then she should seek assistance from additional resources. Telling the mother that her newborn might have testicular cancer is inaccurate, inappropriate, and could cause the new mother undue worry. Urine will not back up into the scrotum if the infant has a hydrocele. Any nurse caring for the normal newborn should understand basic anatomy.

 

DIF:    Cognitive Level: Apply                  REF:   p. 563            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the primary rationale for nurses wearing gloves when handling the newborn?
a. To protect the baby from infection
b. As part of the Apgar protocol
c. To protect the nurse from contamination by the newborn
d. Because the nurse has the primary responsibility for the baby during the first 2 hours

 

 

ANS:  C

With the possibility of transmission of viruses such as HBV and the human immunodeficiency virus (HIV) through maternal blood and amniotic fluid, the newborn must be considered a potential contamination source until proven otherwise. As part of Standard Precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing. Proper hand hygiene is all that is necessary to protect the infant from infection. Wearing gloves is not necessary to complete the Apgar score assessment. The nurse assigned to the mother-baby couplet has primary responsibility for the newborn, regardless of whether or not she wears gloves.

 

DIF:    Cognitive Level: Understand          REF:   p. 549

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. At 1 minute after birth a nurse assesses an infant and notes a heart rate of 80 beats per minute, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. Which Apgar score does the nurse calculate based upon these observations and signs?
a. 4
b. 5
c. 6
d. 7

 

 

ANS:  B

Each of the five signs the nurse notes scores a 1 on the Apgar scale, for a total of 5. A score of 4 is too low for this infant. A score of 6 is too high for this infant. A score of 7 is too high for an infant with this presentation.

 

DIF:    Cognitive Level: Apply                  REF:   p. 551

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

  1. Which statement accurately describes an appropriate-for-gestational age (AGA) weight assessment?
a. AGA weight assessment falls between the 25th and 75th percentiles for the infant’s age.
b. AGA weight assessment depends on the infant’s length and the size of the newborn’s head.
c. AGA weight assessment falls between the 10th and 90th percentiles for the infant’s age.
d. AGA weight assessment is modified to consider intrauterine growth restriction (IUGR).

 

 

ANS:  C

An AGA weight falls between the 10th and 90th percentiles for the infant’s age. The AGA range is larger than the 25th and 75th percentiles. The infant’s length and head size are measured, but these measurements do not affect the normal weight designation. IUGR applies to the fetus, not to the newborn’s weight.

 

DIF:    Cognitive Level: Understand          REF:   p. 553            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is completing a physical examination of the newborn 24 hours after birth. Which component of the evaluation is correct?
a. The parents are excused to reduce their normal anxiety.
b. The nurse can gauge the neonate’s maturity level by assessing his or her general appearance.
c. Once often neglected, blood pressure is now routinely checked.
d. When the nurse listens to the neonate’s heart, the S1 and S2 sounds can be heard; the S1 sound is somewhat higher in pitch and sharper than the S2 sound.

 

 

ANS:  B

The nurse is looking at skin color, alertness, cry, head size, and other features. The parents’ presence actively involves them in child care and gives the nurse the chance to observe their interactions. Blood pressure is not usually taken unless cardiac problems are suspected. The S2 sound is higher and sharper than the S1 sound.

 

DIF:    Cognitive Level: Apply                  REF:   p. 551

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients?
a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases.
b. Federal law prohibits newborn genetic testing without parental consent.
c. If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks.
d. Hearing screening is now mandated by federal law.

 

 

ANS:  C

If testing is performed before the infant is 24 hours old, then genetic screening should be repeated when the infant is 1 to 2 weeks old. All states test for PKU and hypothyroidism but not for other genetic defects. Federal law mandates newborn genetic screening; however, parents can decline the testing. A waiver should be signed, and a notation made in the infant’s medical record. Federal law does not mandate screening for hearing problems; however, the majority of states have enacted legislation mandating newborn hearing screening. In the United States, the majority (95%) of infants are screened for hearing loss before discharge from the hospital.

 

DIF:    Cognitive Level: Apply                  REF:   p. 575            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiologic Integrity

 

  1. Which explanation will assist the parents in their decision on whether they should circumcise their son?
a. The circumcision procedure has pros and cons during the prenatal period.
b. American Academy of Pediatrics (AAP) recommends that all male newborns be routinely circumcised.
c. Circumcision is rarely painful, and any discomfort can be managed without medication.
d. The infant will likely be alert and hungry shortly after the procedure.

 

 

ANS:  A

Parents need to make an informed choice regarding newborn circumcision, based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families should provide factual, unbiased information regarding circumcision and give parents opportunities to discuss the risks and benefits of the procedure. The AAP and other professional organizations note the benefits but stop short of recommending routine circumcision. Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures. After the procedure, the infant may be fussy for several hours, or he may be sleepy and difficult to awaken for feeding.

 

DIF:    Cognitive Level: Understand          REF:   p. 580            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. What approach should the nurse take when performing the test to prevent this complication?
a. Lancet should penetrate at the outer aspect of the heel.
b. Lancet should penetrate the walking surface of the heel.
c. Lancet should penetrate the ball of the foot.
d. Lancet should penetrate the area just below the fifth toe.

 

 

ANS:  A

The stick should be made at the outer aspect of the heel and should penetrate no deeper than 2.4 mm. Repeated trauma to the walking surface of the heel can cause fibrosis and scarring that can lead to problems with walking later in life. The ball of the foot and the area below the fifth toe are inappropriate sites for a heelstick.

 

DIF:    Cognitive Level: Apply                  REF:   p. 576

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiologic Integrity

 

  1. If the newborn has excess secretions, the mouth and nasal passages can be easily cleared with a bulb syringe. How should the nurse instruct the parents on the use of this instrument?
a. Avoid suctioning the nares.
b. Insert the compressed bulb into the center of the mouth.
c. Suction the mouth first.
d. Remove the bulb syringe from the crib when finished.

 

 

ANS:  C

The mouth should always be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. After compressing the bulb, the syringe should be inserted into one side of the mouth. If it is inserted into the center of the mouth, then the gag reflex is likely to be initiated. When the infant’s cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The nasal passages should be suctioned one nostril at a time. The bulb syringe should remain in the crib so that it is easily accessible if needed again.

 

DIF:    Cognitive Level: Apply                  REF:   p. 567

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. As part of the infant discharge instructions, the nurse is reviewing the use of the infant car safety seat. Which information is the highest priority for the nurse to share?
a. Infant carriers are okay to use until an infant car safety seat can be purchased.
b. For traveling on airplanes, buses, and trains, infant carriers are satisfactory.
c. Infant car safety seats are used for infants only from birth to 15 pounds.
d. Infant car seats should be rear facing and placed in the back seat of the car.

 

 

ANS:  D

An infant placed in the front seat could be severely injured by an air bag that deploys during an automobile accident. Infants should travel only in federally approved, rear-facing safety seats secured in the rear seat and only in federally approved safety seats even when traveling on a commercial vehicle. Infants should use a rear-facing car seat from birth to 20 pounds and to age 1 year.

 

DIF:    Cognitive Level: Apply                  REF:   p. 589            TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. A nurse is responsible for teaching new parents regarding the hygienic care of their newborn. Which instruction should the nurse provide regarding bathing?
a. Avoid washing the head for at least 1 week to prevent heat loss.
b. Sponge bathe the newborn for the first month of life.
c. Cleanse the ears and nose with cotton-tipped swabs, such as Q-tips.
d. Create a draft-free environment of at least 24° C (75° F) when bathing the infant.

 

 

ANS:  D

The temperature of the room should be 24° C (75° F), and the bathing area should be free of drafts. To prevent heat loss, the infant’s head should be bathed before unwrapping and undressing. Tub baths may be initiated from birth. Ensure that the infant is fully immersed. Q-tips should not be used; they may cause injury. A corner of a moistened washcloth should be twisted into shape so that it can be used to cleanse the ears and nose.

 

DIF:    Cognitive Level: Apply                  REF:   p. 595            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A 3.8-kg infant was vaginally delivered at 39 weeks of gestation after a 30-minute second stage. A nuchal cord occurred. After the birth, the infant is noted to have petechiae over the face and upper back. Based on the nurse’s knowledge, which information regarding petechiae should be shared with the parents?
a. Petechiae (pinpoint hemorrhagic areas) are benign if they disappear within 48 hours of childbirth.
b. These hemorrhagic areas may result from increased blood volume.
c. Petechiae should always be further investigated.
d. Petechiae usually occur with a forceps delivery.

 

 

ANS:  A

Petechiae that are acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this infant, the presence of petechiae is more likely a soft-tissue injury resulting from the nuchal cord at birth. Unless the lesions do not dissipate in 2 days, no reason exists to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

 

DIF:    Cognitive Level: Apply                  REF:   p. 570

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A mother expresses fear about changing her infant’s diaper after he is circumcised. What does the client need to be taught to care for her newborn son?
a. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
b. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs.
c. Gently cleanse the penis with water and apply petroleum jelly around the glans after each diaper change.
d. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.

 

 

ANS:  C

Gently cleansing the penis with water and applying petroleum jelly around the glans after each diaper change are appropriate techniques when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed with warm water to remove any urine or feces. If bleeding occurs, then the mother should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates are part of normal healing and cover the glans penis 24 hours after the circumcision; yellow exudates are not an infective process and should not be removed.

 

DIF:    Cognitive Level: Apply                  REF:   p. 582            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the nurse’s initial action while caring for an infant with a slightly decreased temperature?
a. Immediately notify the physician.
b. Place a cap on the infant’s head, and have the mother perform kangaroo care.
c. Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours.
d. Change the formula; a decreased body temperature is a sign of formula intolerance.

 

 

ANS:  B

Keeping the head well covered with a cap prevents further heat loss from the head, and placing the infant skin-to-skin against the mother should increase the infant’s temperature. Nursing actions are needed first to correct the problem. If the problem persists after the interventions, physician notification may then be necessary. A slightly decreased temperature can be treated in the mother’s room, offering an excellent time for parent teaching on the prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days after childbirth as the infant adapts to external life.

 

DIF:    Cognitive Level: Apply                  REF:   p. 568

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. How should the nurse interpret an Apgar score of 10 at 1 minute after birth?
a. The infant is having no difficulty adjusting to extrauterine life and needs no further testing.
b. The infant is in severe distress and needs resuscitation.
c. The nurse predicts a future free of neurologic problems.
d. The infant is having no difficulty adjusting to extrauterine life but should be assessed again at 5 minutes after birth.

 

 

ANS:  D

An initial Apgar score of 10 is a good sign of healthy adaptation; however, the test must be repeated at the 5-minute mark.

 

DIF:    Cognitive Level: Understand          REF:   p. 550            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse should be cognizant of which important statement regarding care of the umbilical cord?
a. The stump can become easily infected.
b. If bleeding occurs from the vessels of the cord, then the nurse should immediately call for assistance.
c. The cord clamp is removed at cord separation.
d. The average cord separation time is 5 to 7 days.

 

 

ANS:  A

The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If bleeding occurs and does not stop, then the nurse should call for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

 

DIF:    Cognitive Level: Understand          REF:   p. 593            TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Based on the most recent evidence, which information is incorrect and should be discussed with parents?
a. Prevent exposure to people with upper respiratory tract infections.
b. Keep the infant away from secondhand smoke.
c. Avoid loose bedding, water beds, and beanbag chairs.
d. Place the infant on his or her abdomen to sleep.

 

 

ANS:  D

The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome (SIDS). Grandmothers may encourage the new parents to place the infant on the abdomen; however, evidence shows “back to sleep” reduces SIDS. Infants are vulnerable to respiratory infections; therefore, infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding and in furniture that can trap them. Per AAP guidelines, infants should always be placed “back to sleep” and allowed tummy time to play to prevent plagiocephaly.

 

DIF:    Cognitive Level: Apply                  REF:   p. 589            TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Which intervention by the nurse would reduce the risk of abduction of the newborn from the hospital?
a. Instructing the mother not to give her infant to anyone except the one nurse assigned to her that day
b. Applying an electronic and identification bracelet to the mother and the infant
c. Carrying the infant when transporting him or her in the halls
d. Restricting the amount of time infants are out of the nursery

 

 

ANS:  B

A measure taken by many facilities is to band both the mother and the baby with matching identification bracelets and band the infant with an electronic device that will sound an alarm if the infant is removed from the maternity unit. It is impossible for one nurse to be on call for one mother and baby for the entire shift; therefore, parents need to be able to identify the nurses who are working on the unit. Infants should always be transported in their bassinette for both safety and security reasons. All maternity unit nursing staff should have unique identification bracelets in comparison with the rest of the hospital. Infants should remain with their parents and spend as little time in the nursery as possible.

 

DIF:    Cognitive Level: Apply                  REF:   p. 578

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct?
a. Ideally, the visit is scheduled within 72 hours after discharge.
b. Home visits are available in all areas.
c. Visits are completed within a 30-minute time frame.
d. Blood draws are not a part of the home visit.

 

 

ANS:  A

The home visit is ideally scheduled within 72 hours after discharge. This timing allows early assessment and intervention for problems with feedings, jaundice, newborn adaptation, and maternal-infant interaction. Because of geographic distances, home visits are not available in all locales. Visits are usually 60 to 90 minutes in length to allow enough time for assessment and teaching. When jaundice is found, the nurse can discuss the implications and check the transcutaneous bilirubin level or draw blood for testing.

 

DIF:    Cognitive Level: Apply                  REF:   p. 594            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Screening for critical congenital heart disease (CCHD) was added to the uniform screening panel in 2011. The nurse has explained this testing to the new mother. Which action by the nurse related to this test is correct?
a. Screening is performed when the infant is 12 hours of age.
b. Testing is performed with an electrocardiogram.
c. Oxygen (O2) is measured in both hands and in the right foot.
d. A passing result is an O2 saturation of ³95%.

 

 

ANS:  D

Screening is performed when the infant is between 24 and 48 hours of age. The test is performed using pulse oximetry technology. O2 is measured in the right hand and one foot. A passing result is an O2 saturation of ³95% with a £3% absolute difference between upper and lower extremity readings.

 

DIF:    Cognitive Level: Analyze               REF:   p. 576

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

MULTIPLE RESPONSE

 

  1. Pain should be regularly assessed in all newborns. If the infant is displaying physiologic or behavioral cues that indicate pain, then measures should be taken to manage the pain. Which interventions are examples of nonpharmacologic pain management techniques? (Select all that apply.)
a. Swaddling
b. Nonnutritive sucking
c. Skin-to-skin contact with the mother
d. Sucrose
e. Acetaminophen

 

 

ANS:  A, B, C, D

Swaddling, nonnutritive sucking, skin-to-skin contact with the mother, and sucrose are all appropriate nonpharmacologic techniques used to manage pain in neonates. Acetaminophen is a pharmacologic method of treating pain.

 

DIF:    Cognitive Level: Understand          REF:   pp. 584-585

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiologic Integrity

 

  1. As recently as 2005, the AAP revised safe sleep practices to assist in the prevention of SIDS. The nurse should model these practices in the hospital and incorporate this information into the teaching plan for new parents. Which practices are ideal for role modeling? (Select all that apply.)
a. Fully supine position for all sleep
b. Side-sleeping position as an acceptable alternative
c. “Tummy time” for play
d. Infant sleep sacks or buntings
e. Soft mattress

 

 

ANS:  A, C, D

The “back to sleep” position is now recommended as the only position for every sleep period. To prevent positional plagiocephaly (flattening of the head) the infant should spend time on his or her abdomen while awake and for play. Loose sheets and blankets may be dangerous because they could easily cover the baby’s head. The parents should be instructed to tuck any bedding securely around the mattress or use sleep sacks or bunting bags instead. The side-sleeping position is no longer an acceptable alternative position, according to the AAP. Infants should always sleep on a firm surface, ideally a firm crib mattress covered by a sheet only. Quilts and sheepskins, among other bedding, should not be placed under the infant.

 

DIF:    Cognitive Level: Apply                  REF:   p. 590

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The “Period of Purple Crying” is a program developed to educate new parents about infant crying and the dangers of shaking a baby. Each letter in the acronym “PURPLE” represents a key concept of this program. Which concepts are accurate? (Select all that apply.)
a. P: peak of crying and painful expression
b. U: unexpected
c. R: baby is resting at last
d. L: extremely loud
e. E: evening

 

 

ANS:  A, B, E

P: peak of crying; U: unexpected—comes and goes; R: resists soothing; P: pain—line face; L: long—lasting up to 5 hours a day; and E: evening or late afternoon. Many hospitals now provide parents with an educational DVD and provide education before discharge.

 

DIF:    Cognitive Level: Analyze               REF:   p. 596

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Hearing loss is one of the genetic disorders included in the universal screening program. Auditory screening of all newborns within the first month of life is recommended by the AAP. What is the rationale for having this testing performed? (Select all that apply.)
a. Prevents or reduces developmental delays
b. Reassures concerned new parents
c. Provides early identification and treatment
d. Helps the child communicate better
e. Is recommended by the Joint Committee on Infant Hearing

 

 

ANS:  A, C, D, E

New parents are often anxious regarding auditory screening and its impending results; however, parental anxiety is not the reason for performing the screening test. Auditory screening is usually performed before hospital discharge. Importantly, the nurse ensures the parents that the infant is receiving appropriate testing and fully explains the test to the parents. For infants who are referred for further testing and follow-up, providing further explanation and emotional support to the parents is an important responsibility for the nurse. All other responses are appropriate reasons for auditory screening of the newborn. Infants who do not pass the screening test should have it repeated. If the infant still does not pass the test, then he or she should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in an early intervention program by 6 months of age.

 

DIF:    Cognitive Level: Apply                  REF:   pp. 575-576   TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Physiologic Integrity

 

Chapter 36: Hemolytic Disorders and Congenital Anomalies

Lowdermilk: Maternity & Women’s Health Care, 11th Edition

 

MULTIPLE CHOICE

 

  1. To explain hemolytic disorders in the newborn to new parents, the nurse who cares for the newborn population must be aware of the physiologic characteristics related to these conditions. What is the most common cause of pathologic hyperbilirubinemia?
a. Hepatic disease
b. Hemolytic disorders
c. Postmaturity
d. Congenital heart defect

 

 

ANS:  B

Hemolytic disorders in the newborn are the most common cause of pathologic hyperbilirubinemia (jaundice). Although hepatic damage, prematurity, and congenital heart defects may cause pathologic hyperbilirubinemia, they are not the most common causes.

 

DIF:    Cognitive Level: Apply                  REF:   p. 882            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Physiologic Integrity

 

  1. Which infant is most likely to express Rh incompatibility?
a. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor
b. Infant who is Rh negative and a mother who is Rh negative
c. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor
d. Infant who is Rh positive and a mother who is Rh positive

 

 

ANS:  A

If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, then all the offspring of this union will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. Only the Rh-positive offspring of an Rh-negative mother are at risk. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, a 50% chance exists that each infant born of this union will be Rh positive, and a 50% chance exists that each will be born Rh negative. No risk for incompatibility exists if both the mother and the infant are Rh positive.

 

DIF:    Cognitive Level: Understand          REF:   p. 883            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the highest priority nursing intervention for an infant born with myelomeningocele?
a. Protect the sac from injury.
b. Prepare the parents for the child’s paralysis from the waist down.
c. Prepare the parents for closure of the sac when the child is approximately 2 years of age.
d. Assess for cyanosis.

 

 

ANS:  A

A major preoperative nursing intervention for a neonate with a myelomeningocele is the protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system (CNS) infection. The long-term prognosis in an affected infant can be determined to a large extent at birth, with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. A myelomeningocele should be surgically closed within 24 hours. Although the nurse should assess for multiple potential problems in this infant, the major nursing intervention is to protect the sac from injury.

 

DIF:    Cognitive Level: Understand          REF:   p. 892

TOP:   Nursing Process: Planning | Nursing Process: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. Which nursing diagnosis is most appropriate for a newborn diagnosed with a diaphragmatic hernia?
a. Risk for impaired parent-infant attachment
b. Imbalanced nutrition, related to less than body requirements
c. Risk for infection
d. Impaired gas exchange

 

 

ANS:  D

Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. Although imbalanced nutrition, related to less than body requirements, may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. The nutritional needs of this infant may be a clearly identified need; however, at this time the nurse should be most concerned about impaired gas exchange. This infant is at risk for infection, especially once the surgical repair has been performed. The extent of the herniation may have hindered normal development of the lungs in utero, resulting in respiratory distress.

 

DIF:    Cognitive Level: Apply                  REF:   p. 894            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Physiologic Integrity

 

  1. What is the clinical finding most likely to be exhibited in an infant diagnosed with erythroblastosis fetalis?
a. Edema
b. Immature red blood cells
c. Enlargement of the heart
d. Ascites

 

 

ANS:  B

Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. Edema occurs with hydrops fetalis, a more severe form of erythroblastosis fetalis. The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces, as well as demonstrate signs of ascites.

 

DIF:    Cognitive Level: Understand          REF:   p. 883

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

  1. Which statement regarding congenital anomalies of the cardiovascular and respiratory systems is correct?
a. Cardiac disease may demonstrate signs and symptoms of respiratory illness.
b. Screening for congenital anomalies of the respiratory system need only be performed for infants experiencing respiratory distress.
c. Choanal atresia can be corrected with the use of a suction catheter to remove the blockage.
d. Congenital diaphragmatic hernias are diagnosed and treated after birth.

 

 

ANS:  A

The cardiac and respiratory systems function together; therefore, initial findings will be related to respiratory illness. Screening for congenital respiratory system anomalies is necessary, even for infants who appear normal at birth. All newborns should have critical congenital heart disease (CCHD) screening performed before discharge. Choanal atresia requires emergency surgery. Congenital diaphragmatic hernias are prenatally discovered on ultrasound.

 

DIF:    Cognitive Level: Understand          REF:   p. 889

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

  1. When attempting to screen and educate parents regarding the treatment of developmental dysplasia of the hip (DDH), which intervention should the nurse perform?
a. Be able to perform the Ortolani and Barlow tests.
b. Teach double or triple diapering for added support.
c. Explain to the parents the need for serial casting.
d. Carefully monitor infants for DDH at follow-up visits.

 

 

ANS:  D

Because DDH often is not detected at birth, infants should be carefully monitored at follow-up visits. The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. Double or triple diapering is not recommended because it promotes hip extension, thus worsening the problem. Serial casting is recommended for clubfoot, not DDH.

 

DIF:    Cognitive Level: Apply                  REF:   p. 899            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is assigned a home care visit of a 5-day-old infant for the treatment of jaundice. A thorough assessment is completed, and a health history is obtained. Which sign or symptom indicates that the infant may be displaying the initial phase of encephalopathy?
a. High-pitched cry
b. Severe muscle spasms (opisthotonos)
c. Fever and seizures
d. Hypotonia, lethargy, and poor suck

 

 

ANS:  D

The early and most subtle symptoms of bilirubin encephalopathy include hypotonia, lethargy, poor suck, and a depressed or absent Moro reflex. Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or an arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase of encephalopathy. Medical attention is immediately necessary. Symptoms may progress from the subtle indications of the first phase to fever and seizures in as few as 24 hours. Only approximately one half of these infants survive, and those that do will have permanent sequelae, including auditory deficiencies, intellectual deficits, and movement abnormalities.

 

DIF:    Cognitive Level: Analyze               REF:   p. 884

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Most congenital anomalies of the CNS result from defects in the closure of the neural tube during fetal development. Which factor has the greatest impact on this process?
a. Maternal diabetes
b. Maternal folic acid deficiency
c. Socioeconomic status
d. Maternal use of anticonvulsant

 

 

ANS:  B

All of these environmental influences may affect the development of the CNS. Maternal folic acid deficiency has a direct bearing on the failure of neural tube closure. As a preventative measure, folic acid supplementation (0.4 mg/day) is recommended for all women of childbearing age.

 

DIF:    Cognitive Level: Analyze               REF:   p. 891            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiologic Integrity

 

  1. The condition, hypospadias, encompasses a wide range of penile abnormalities. Which information should the nurse provide to the anxious parents of an affected newborn?
a. Mild cases involve a single surgical procedure.
b. Infant should be circumcised.
c. Repair is performed as soon as possible after birth.
d. No correlation exists between hypospadia and testicular cancer.

 

 

ANS:  A

Mild cases of hypospadias are often repaired for cosmetic reasons, and repair involves a single surgical procedure, enabling the male child to urinate in a standing position and to have an adequate sexual organ. These infants are not circumcised; the foreskin will be needed during the surgical repair. Repair is usually performed between 1 and 2 years of age. A correlation between hypospadias and testicular cancer exists; therefore, these children will require long-term follow-up observation.

 

DIF:    Cognitive Level: Apply                  REF:   p. 902

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is instructing a family how to care for their infant in a Pavlik harness to treat DDH. What information should be included in the teaching?
a. Apply lotion or powder to minimize skin irritation.
b. Remove the harness several times a day to prevent contractures.
c. Return to the clinic every 1 to 2 weeks.
d. Place a diaper over the harness, preferably using an absorbent disposable diaper.

 

 

ANS:  C

Infants have a rapid growth pattern. Therefore, the child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness, and the harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

 

DIF:    Cognitive Level: Understand          REF:   p. 900

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiologic Integrity

 

  1. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, how should the nurse respond?
a. Traction is tried first.
b. Surgical intervention is needed.
c. Frequent, serial casting is tried first.
d. Children outgrow this condition when they learn to walk.

 

 

ANS:  C

Serial casting, the preferred treatment, is begun shortly after birth and before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are frequently repeated (every week) to accommodate the rapid growth of early infancy. Surgical intervention is performed only if serial casting is not successful. Children do not improve without intervention.

 

DIF:    Cognitive Level: Understand          REF:   p. 901            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiologic Integrity

 

  1. Which statement regarding hemolytic diseases of the newborn is most accurate?
a. Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother.
b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia.
c. Exchange transfusions are frequently required in the treatment of hemolytic disorders.
d. The indirect Coombs’ test is performed on the mother before birth; the direct Coombs’ test is performed on the cord blood after birth.

 

 

ANS:  D

An indirect Coombs’ test may be performed on the mother a few times during pregnancy. Only the Rh-positive child of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers infrequently are needed because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

 

DIF:    Cognitive Level: Understand          REF:   pp. 884, 885  TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from the failure of the primary palate to fuse. Multiple genetic and, to a lesser extent, environmental factors may lead to the development of a cleft lip or palate. Which factors are included? (Select all that apply.)
a. Alcohol consumption
b. Female gender
c. Use of some anticonvulsant medications
d. Maternal cigarette smoking
e. Antibiotic use in pregnancy

 

 

ANS:  A, C, D

Factors associated with the potential development of cleft lip or palate are maternal infections, alcohol consumption, radiation exposure, corticosteroid use, use of some anticonvulsant medications, male gender, Native-American or Asian descent, and maternal smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate.

 

DIF:    Cognitive Level: Understand          REF:   p. 895            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiologic Integrity

 

  1. The most widespread use of postnatal testing for genetic disease is the routine screening of newborns for inborn errors of metabolism (IEM). Which conditions are considered metabolic disorders? (Select all that apply.)
a. Phenylketonuria (PKU)
b. Galactosemia
c. Hemoglobinopathy
d. Cytomegalovirus (CMV)
e. Rubella

 

 

ANS:  A, B, C

PKU is an IEM that can be diagnosed with newborn screening. Galactosemia is a metabolic defect that falls under the category of an IEM. Sickle cell disease and thalassemia are hemoglobinopathies that can be detected by newborn screening. CMV and rubella cannot be detected by newborn screening and are not metabolic disorders; rather, they are viruses contracted by the fetus.

 

DIF:    Cognitive Level: Understand          REF:   p. 904            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is caring for an infant with DDH. Which clinical manifestations should the nurse expect to observe? (Select all that apply.)
a. Positive Ortolani click
b. Unequal gluteal folds
c. Negative Babinski sign
d. Trendelenburg sign
e. Telescoping of the affected limb

 

 

ANS:  A, B

A positive Ortolani test and unequal gluteal folds are clinical manifestations of DDH observed from birth to 2 to 3 months of age. A negative Babinski sign, Trendelenburg sign, and telescoping of the affected limb are not clinical manifestations of DDH.

 

DIF:    Cognitive Level: Apply                  REF:   p. 900            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

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