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Are all probable signs of pregnancy -
changes that make the examiner suspect a woman is pregnant
(related to physical changes of the uterus).
Goodell’s sign, ballottement, Chadwick’s sign, Hegar’s sign, Abdominal enlargement related to changes in uterine size, shape, & position, fetal outline felt by examiner, Braxton Hicks contractions,Positive pregnancy test
Softening and compressibility of the lower uterus
Deepened violet-bluish color of vaginal mucosa secondary to
increased vascularity of the area.
Softening of cervical tip
Rebound of unengaged fetus
Painless, irregular contractions that are usually relieved with
Slight fluttering movements of fetus felt by a woman
Mask of pregnancy (pigmentation increases on the face)
Dark line of pigmentation from the umbilicus to the pubic
Stretch marks most often found on the abdomen and thighs
A rn is teaching a group of women who are pregnant about measures to relieve backache during pregnancy. The nurse should teach the women...
Perform the pelvic rock exercise every day.
Use good body mechanics.
A rn is teaching a group of clients who are pregnant about behaviors to avoid during pregnancy. The client needs further instruction when
No alcohol should be consumed during pregnancy.
A client who is at 8 weeks of gestation tells the rn that she isn’t sure she is happy about being pregnant. The rn should respond to the client by
Ambivalence during the first trimester is a normal response. The client usually overcomes
ambivalence before the second trimester.
A client who is pregnant should promptly report which of the following symptoms to the primary care provider?
Vaginal bleeding during pregnancy is always a dangerous sign and the client should notify
her primary care provider.
A client who is at 7 weeks of gestation is experiencing N/V in the morning. The nurse in the prenatal clinic provides teaching that should include
Eat crackers or plain toast before getting out of bed.
Nausea and vomiting may occur during the first trimester. The client should eat crackers or
dry toast ½ to 1 hr before rising in the morning to relieve discomfort.
RN working in a prenatal clinic is providing education to a client who is pregnant. The client states that she hates milk. A good source of calcium
Dark green, leafy vegetables
Calcium is very important to a developing fetus. It is involved in bone and teeth formation.
Good sources of calcium include calcium-fortified orange juice, nuts, legumes, and low
oxalate, dark green, leafy vegetables.
Which of the following clients should the nurse be concerned about regarding weight gain? A client who has gained
A client who has gained 3.6 kg (8 lb) in her first trimester has gained too much weight.
Recommended weight gain during pregnancy is usually 11.2 to 15.9 kg (25 to 35 lb).
A prenatal nurse recommends folic acid supplements to a client who is 18. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency?
Folic acid supplements are recommended to prevent neural tube defects in the fetus. It is
recommended that all women of childbearing age take this supplement. fresh green, leafy vegetables, liver, peanuts, cereals, and wholegrain breads.
A pregnant client is diagnosed with iron deficiency anemia and has been prescribed iron
supplements. The rn should advise the client to
Orange juice contains vitamin C, which aids in the absorption of iron.
A nurse is evaluating a client’s biophysical profile (BPP). Which of the following are variables should
be included in this test?
BPP assesses the fetal well-being by measuring, Fetal breathing, tone, reactive FHR, amniotic
fluid volume, and gross body movements
with a score of 2 for each normal finding, and 0
for each abnormal finding for each variable.
Which of the following is a test for fetal lung maturity?
An L/S ratio of 2:1 indicates fetal lung maturity (2.5:1 or 3:1 for a client who has diabetes
A client who is undergoing a nonstress test asks a rn to explain why use an acoustic vibration device. The rn states that the device is used to
If there is no fetal movement (fetus sleeping), vibroacoustic stimulation (sound source,
usually a laryngeal stimulator) is activated for 3 seconds on the maternal abdomen over the
fetal head to awaken a sleeping fetus
A nurse determines that a client who is pregnant needs further instructions about an amniocentesis
when the client states,
“I need to have a full bladder for the procedure to be done.”
An amniocentesis requires an empty bladder to prevent an inadvertent puncture from
Which findings from a client who is pregnant should indicate to a nurse that the client should undergo a contraction stress test (CST)?
Decreased fetal movement, Intrauterine growth restriction (IUGR)
Advanced maternal age,
are all findings that require interventions. Assessing fetal well-being by performing a CST would be indicated.
Signs and symptoms of an ectopic pregnancy include unilateral lower-quadrant abdominal
pain with or without bleeding.
Risk Factors for Abrutio Placenta
Maternal hypertension, blunt abdominal trauma, cocaine abuse, and cigarette smoking are
risk factors for abruption placenta.
A client who is at 32 weeks gestation, is diagnosed with placenta
previa & is actively bleeding. The RN anticipates what medication to be ordered
Corticosteroids (Betamethasone) will be prescribed for fetal lung maturation if delivery of
the fetus is anticipated (cesarean birth).
A client presents to L&D with stabbing abdominal pain, rigid abdomen and heavy, bright red bleeding. The nurse is aware that these findings are
Abruptio placenta is the sudden onset of intense localized uterine pain with bright red
vaginal bleeding. An abdomen that is both rigid and tender is also a common assessment
A nurse on the obstetrical unit admitted a client who is in labor. The client is HIV status. The nurse is aware that ...
An episiotomy is contraindicated for clients who are HIV+ due to the risk of maternal
blood exposure. Also, the use of internal fetal monitors, vacuum extraction, and
forceps during labor should be avoided because of the risk of fetal bleeding
A nurse in an antepartum clinic is providing care for a client. Which of the following clinical findings
are suggestive of TORCH?
Symptoms of TORCH are flu-like in presentation. They may include reports of joint pain,
malaise, rash, and tender lymph nodes.
A RN is caring for a client who is diagnosed with gonorrhea. Which medications should the nurse anticipate the provider will prescribe?
Ceftriaxone (Rocephin) or
doxycycline (Vibramycin) orally for 7 days is prescribed for the treatment
Which of the following conditions has medications that can be prescribed as prophylactic treatment during labor or
immediately following delivery?
Streptococcus ß-hemolytic, Group B
Magnesium sulfate is an anticonvulsant that would be prescribed for a client who is
exhibiting signs and symptoms of severe preeclampsia as evidenced by this client’s elevated
blood pressure and 3+ proteinuria.
A client at 14 weeks of gestation who is diagnosed with hyperemesis gravidarum. Which of the following are risk factors for this client?
Risk factors for hyperemesis gravidarum include obesity, multifetal gestation, vitamin B
deficiencies, and maternal age less than 20.
A rn is administering magnesium sulfate IV to a client with severe preeclampsia for seizure prophylaxis. Which indicate magnesium sulfate toxicity?
Signs of magnesium sulfate toxicity include the absence of patellar deep-tendon reflexes,
urine output less than 30 mL/hr, respirations less than 12/min, and a decreased level of
Which of the following classifications of heart disease is the client symptomatic with marked
limitations on physical activity?
The classification system will guide the provider in the management of cardiovascular
disease. Clients exhibiting symptoms with marked limitations on physical activity are
in Class III.
client is diagnosed w/ mitral valve prolapse. The ECG
reveals tachyarrhythmias. Which medication should the rn anticipate the PCP will prescribe?
Propranolol (Inderal) is prescribed to treat arrhythmias.
A client who is prescribed terbutaline (Brethine) 0.25 mg subcutaneously. Which of the following is an adverse effect of this medication?
Maternal tachycardia is a normal adverse effect that will decrease over time.
a client at 32 weeks gestation,
is diagnosed with preterm labor. Which medication should the
PCP prescribe to hasten fetal lung maturity?
a glucocorticoid that is given to clients in preterm labor to hasten
Uterine contractions and cervical changes that
occur between 20 and 37 weeks of gestation
Premature rupture of
Spontaneous rupture of the amniotic membranes
1 hr or more prior to the onset of true labor
Preterm premature rupture
Spontaneous rupture of membranes after 20
weeks of gestation and prior to 37 weeks of
Infection of the amniotic membranes
A client who is prescribed magnesium sulfate. The nurse recognizes that which of
the following is a contraindication for use of this medication
Acute fetal distress, cervical dilation > 6 cm, vaginal bleeding, and severe pregnancy-induced hypertension are complications that are contraindicated by the use of magnesium sulfate to stop labor.
They require immediate delivery of the fetus.
True contractions do not go away with hydration or walking. Instead, they are regular
in frequency, duration, and intensity, and become stronger with walking.
decrease with hydration and walking.
is the downward
movement of the fetus in the birth canal.
Rupture of membranes
is when the amniotic
membranes rupture and allow the amniotic fluid to escape.
The first stage, latent phase
In stage 1, latent phase, the cervix dilates from 0 to 3 cm and contraction duration ranges
from 30 to 45 seconds.
stage 1, active phase
the cervix dilates from 4 to 7 cm, and
contraction duration ranges from 40 to 70 seconds.
stage 1, transition phase
dilates from 8 to 10 cm, and contraction duration ranges from 45 to 90 seconds.
stage of labor
consists of the expulsion of the fetus.
A client experiences a large gush of fluid from her vagina while walking. The first rn action after establishing that the fluid is amniotic fluid
Conducting an admit Hx for a client at 39 weeks gestation, she tells the
rn that she's been leaking from her vagina for 2 days. The rn knows that
this client is at risk for infection.
Rupture of membranes exceeding 24 hr before delivery increases the risk that infectious
organisms will enter the vagina and then eventually into the uterus.
transition phase of labor
A client, in active labor & becomes nauseous and vomits. The client is
also very irritable & needs to have a bowel movement. She states, “I’ve had enough. I
can’t do this anymore. I want to go home right now.” What labor pahse is the client in?
transition phase of labor.
is the phase where the client becomes irritable, feels rectal
pressure that can feel similar to the need to have a bowel movement, and can become
nauseous with emesis.
is the recovery period
3cm dilated, 80% effaced, and -1station. Client wants pain meds now. RN suggests
Patterned breathing techniques,
Butorphanol (Stadol) 2 mg IV as prescribed,
Application of heat or cold,
Distraction or a focal point.
Nonpharmacological comfort measures can be safely used while the client is
in the latent phase of labor
is the application of steady pressure to the lower back to counteract
the pressure exerted on the spinal nerves by the fetus, which especially occurs with an
occiput posterior presentation.
is a gentle stroking of the abdomen in
rhythm with breathing during contractions.
a back rub, and massage may be
helpful, but counterpressure is most effective in relieving back discomfort.
A crna is explaining an epidural procedure to a client. What is the role of the nurse before, during, and after administration of an epidural?
Administer a bolus of IV fluids prior to epidural insertion.
Have oxygen and suction ready in the event of respiratory depression.
Palpate the client’s bladder for distention and insert indwelling Foley
catheter if necessary.
(Demerol) 50mg IV for pain 30min prior to delivery. Which med
should the rn be prepared to give?
Naloxone (Narcan) to the neonate
(an opioid antagonist) should be administered to the neonate for
A nurse is caring for a client who is in labor. Which of the following should the nurse assess for
following placement of an epidural?
Hypotension in the mother
because it is an adverse effect of epidural analgesia.
Epidural analgesia also causes fetal bradycardia
A pudendal block is a transvaginal injection of a local anesthetic into the area in front of
the pudendal nerve that anesthetizes the perineum, vulva, and rectal areas for episiotomy,
expulsion of the fetus, and episiotomy repair.
Epidural blocks are administered during labor
and allow the client to participate in the labor process while remaining comfortable.
are administered late in the second stage, but most commonly preceding a cesarean
A nurse is caring for a client in labor. The client experiences hypotension and fetal bradycardia.
Which of the following nursing actions should the nurse implement?
The nurse should be prepared to administer ephedrine via an IV bolus, position the client
laterally, increase IV fluids, and initiate oxygen.
It is used to correct neonatal depression caused by maternal opioids.
No FHR decelerations,
Normal baseline FHR
occasional increases up to 150
to 155/min that last for 25 seconds, and have beat-to-beat variability of 20/min.
client is exhibiting signs of which of
Which of the following should occur first for an
internal scalp electrode to be applied?
Prior to the insertion of an internal fetal monitor and an intrauterine pressure catheter, the
membranes must first have ruptured. Cervical dilation, effacement, & engagement of the
fetus are also needed.
A nurse is reviewing the fetal monitor tracing of a client who is in active labor. The nurse knows that
a fetus receives more oxygen during?
Relaxation between uterine contractions
With women who are low risk
the FHR should be assessed every 15 min in the second stage
In women who are high risk
FHR should be assessed every 5 min in the second
stage of labor.
Every 60 min
FHR assessments are done during the latent phase for women
who are low risk.
Every 30 min,
assessments are done in the active phase for women who are
low risk and in the latent phase for women who are high risk.
Which of the following is the initial nursing action the nurse should take when late decelerations
appear on the fetal monitor?
Reposition the client in to left-lateral position to increase uteroplacental perfusion.
The greatest risk to the fetus during late decelerations is uteroplacental insufficiency..
Episodic accelerations of the FHR from baseline should be interpreted by the nurse as indicative of
intact CNS response to fetal movement.
A primigravida client at 39 weeks gestation comes to the birthing unit with her partner
because she's been having regular contractions. She states that her “water broke.” What is the nurses priority assessment?
nurse provide the client and coaching partner education during the labor process?
The first stage, latent phase. Because client is not in any pain and is ready to learn.
A client is in the transition phase of labor and feels that she needs to have a BM with the peak of contractions. An appropriate
Prepare for an impending delivery.
The urge to have a bowel movement is
a sign of complete dilation and fetal descent. If
there is fecal material present at the rectum, the nurse should cleanse the perineum rather
than escorting the client to the bathroom. The nurse should not remove a fecal impaction.
The nurse should always assess for signs of a prolapsed cord when membranes rupture.
A client in active labor who's vaginal exam 1 hr ago showed that she was 3 cm
dilated, 50 percent effaced, and had a - 3 station. Her membranes ruptured spontaneously. The nurse should assess her for which sign?
A nurse is palpating the client’s bladder and is encouraging her to void every 1 to 2 hr during labor
predominantly because a
A distended bladder reduces pelvic space, impedes the fetal descent necessary for delivery,
and places the bladder at risk for trauma during the labor process.
Which of the following positions should a nurse place a client in prior to a cesarean birth?
The client will need to be positioned supine, for the cesarean birth. Placing a
wedge under the right hip, will tilt the client so she will not
experience the pressure of her gravid uterus that is compressing on the inferior vena cava.
of 0.9% sodium chloride or lactated Ringer’s solution,
is instilled into the amniotic cavity through a catheter into the
uterus to supplement the amount of amniotic fluid. Helps prevent variable decels caused by cord compression
is an inadequate amount of amniotic fluid, less than 300mL, which
contributes to intrauterine growth restriction of the fetus, restrict fetal movement, and
cause fetal distress during labor.
Meconium staining of the amniotic fluid
fresh meconium places the fetus at risk for meconium aspiration syndrome.
which decreases fetal oxygenation
A client who has meconium stained fluid. Which solutions does
the nurse anticipate the provider to prescribe for an amnioinfusion?
Lactated Ringer’s solution and
0.9% sodium chloride
Prior to the performance of an amniotomy
the amniotic membranes should have ruptured.
It is also imperative that the fetus is engaged at a level 0 station and at the level of the
maternal ischial spines to prevent prolapse of the umbilical cord.
axis of the maternal spine in relation to the axis of the fetal spine.
the relationship of the fetal extremities and chin to the fetal torso.
refers to the
direction of a reference point in the fetal presenting part to the maternal pelvis.
RhO(D) immune globulin (RhoGAM)
Which of the following medications should the nurse anticipate will be necessary to administer
preceding an external version for a client who has Rh-negative blood and did not receive adequate
Discontinue oxytocin (Pitocin) if uterine hyperstimulation occurs with contraction frequency more than
every 2min; contraction duration longer than 90sec; contraction intensity
results with pressures > 90 mmHg as shown by IUPC; and a uterine resting tone
> 20 mmHg between contractions showing no relaxation of uterus between
In addition to oxytocin (Pitocin) administration, what other methods of augmenting or inducing
labor should a nurse anticipate?
If contractions are of too long a duration or do not have complete relaxation or uterine tone in
between contractions, the adverse effect will be
reduced fetal oxygen supply.
a client who is in active labor and reports severe back pain. During assessment,
the fetus is noted to be in the occiput posterior position. Which maternal position
should the nurse suggest to the client to help facilitate normal labor progress?
Prolapsed umbilical cord
A nurse is caring for a client admitted to the labor and delivery unit. With the use of Leopold
maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible
complications should the nurse observe?
prolapsed umbilical cord
is a potential complication for a fetus in a breech presentation.
Breech presentation would most likely cause dystocia (prolonged, difficult labor).
The nurse should be aware that which of the following are risk factors for dysfunctional labor?
Risk factors such as short stature, cephalopelvic disproportion, fetal malpresentation, and
maternal fatigue are risk factors for dysfunctional labor.
A nurse is caring for a client who is at 42 weeks of gestation and in active labor. The nurse should
understand that the fetus is at risk for which of the following?
After delivery, the uterus contracts and gradually returns to its prepregnant state. This is referred to as
Uterine involution is the return of the uterus to the prepregnant state, and postpartum
contractions aid in this occurring.
is a condition in which the uterus
turns inside out and can be caused by the placenta being removed too vigorously prior to its
natural detachment process.
The client has moderate lochia rubra containing small clots with a fleshy odor, which is a
normal finding for the second day postpartum
A nurse is performing a fundal assessment for a client in her 2nd postpartum day and observes the client’s perineal pad for lochia. She notes the pad to be saturated about 12 cm with lochia that is bright red in color and contains small clots.
a normal postural discharge of lochia.
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a RN finds the clients uterus to be firm and midline & at the level of the umbilicus. The nurse interprets this finding as
Urinary retention - can result in a distention of the bladder. A distended bladder can
cause uterine atony and lateral displacement from the midline, usually to the right.
A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is
found to be displaced laterally to the right and there is uterine atony. Which of the following is the
cause of the uterine atony?
If all factors are stable, postpartum assessments of vital signs as well as uterine firmness location, and position should be done every
15 min x 4 for the first hour, every 30 min x 2
for the second hour, hourly x 2 for at least 2 hr, and then every 4 to 8 hr for the remainder
of the client’s hospitalization.
Which of the following nursing interventions will promote comfort for a client who has a small
hematoma of the perineal area?
Apply ice to the perineal area for the first 24 to 48 hr.
Encourage sitz baths at least twice a day.
Use a topical antiseptic cream or spray on the perineal area.
when the father is present.
Nursing interventions to assist the father in bonding with the infant include providing
education about infant care
the taking-in phase
birth and lasts a few hours to a couple of days. The woman is excited
and talkative during this phase and repeatedly reviews the labor and birth experience. It
is important for the nurse to allow her the time to express her feelings.
Demonstrates apathy when the infant cries,
Views the infant’s behavior as uncooperative during diaper changing
A nurse is caring for a client who is 1-day postpartum. The nurse is assessing for maternal adaptation
and mother-infant bonding. Which of the following behaviors by the mother indicates a need for the
nurse to intervene?
Adverse responses from the sibling to a new infant can include
signs of sibling rivalry and
jealousy, regression in toileting and sleep habits, aggression toward the infant, increased
attention-seeking behaviors, and whining.
Some nursing interventions to facilitate sibling
acceptance of the infant include
encouraging the parents to have a gift from the infant to
give the sibling, arranging for one parent to spend time with the sibling while the other
parent is caring for the infant, and giving preschool and school-age kids a doll as their
a client who is 2 weeks postpartum and breastfeeding reports breast engorgement. Which recommendation should the nurse make?
“Apply cold compresses between feedings",
This can help with breast engorgement.
Taking a warm shower prior to feedings, not immediately after, can assist with the letdown
reflex and milk flow.
A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should
contact her PCP for which client findings?
A sore nipple that has cracks and fissures is an indication of mastitis.
Lactating does not prevent pregnancy, even if menses has not yet resumed.
oral contraceptives (mini pills) are a good form of birth control once lactating,
alsp by having her
diaphragm refitted by her PCP, which should be done after a pregnancy
and birth or a 7kg (15lb) weight change.
A client who does not wash her hands between perineal care and breastfeeding
A nurse is providing care to multiple clients on the postpartum unit. Which of the following clients is
at greatest risk for developing a puerperal infection?
A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The
client reports leaking urine every time she sneezes or coughs. The nurse suggests the client perform
what to help alleviate this problem?
Increasing pulse and decreasing blood pressure
A nurse is caring for a postpartum client. The nurse understands that which of the following findings
are the earliest indication of hypovolemia caused by hemorrhage?
A rising pulse rate and decreasing blood pressure
are often the first signs of inadequate blood
Which of the following are risk factors for postpartum hemorrhage?
Precipitous delivery, lacerations, inversion of the uterus, and retained placental fragments
are all risk factors associated with postpartum hemorrhage.
A postpartum RN is caring for a client who has (DVT). Which of the
following clinical findings should the nurse anticipate the client will exhibit?
Calf tenderness, swelling, warm extremity and elevated temperature are clinical findings in
clients who have DVT.
A client with a DVT is being cared for by a postpartum RN. Which
nursing intervention should the nurse include in the client’s plan of care?
leg circumferences, applying warm moist compresses to the affected extremity, and
instructing the client to remain on bed rest with the affected extremity elevated.
A nurse is caring for a client who has (DIC). Which antepartum complication should the nurse understand is a risk factor for this client?
disseminated intravascular coagulation (DIC)
may occur secondary in a client who has preeclampsia.
A nurse is caring for a client who is experiencing postpartum hemorrhage. What
should the nurse use to replace fluid volume in this client?
Fluid volume replacement should be with IV isotonic solutions such as lactated Ringer’s
solution or 0.9% sodium chloride, colloid volume expanders, such as albumin and blood
products (packed RBCs and fresh frozen plasma).
A client who is at the greatest risk for postpartum infection is the client who
has premature rupture of membranes and prolonged labor.
A nurse is caring for a client who is breastfeeding and has mastitis. Which of the following should the
nurse teach the client?
“Completely empty each breast at each feeding or with a pump.”
“I will perform peri care and apply a perineal pad in a back/front
direction.” & “I wont nurse my baby until I have finished taking the antibiotic.”
A postpartum client who is being d/c'd 2 days after delivery has been diagnosed with a UTI. The nurse reviews discharge instructions with the client. Which of the following
statements by the client indicates a need for further teaching?
A nurse is caring for a client who has mastitis. Which of the following is the typical causative agent of
A nurse is assessing a postpartum client who is exhibiting signs of tearfulness, insomnia, lack of
appetite, and a feeling of letdown. The nurse knows these signs and symptoms are characteristics of
Identify contributing factors of postpartum depression.
from the labor & birth, socioeconomic factors, maternal anxiety about assuming a new
role, the rapid decline in maternal estrogen and progesterone levels w/ the expulsion of the
placenta, & postpartum physical discomfort/pain.
a postpartum client who delivered her third infant 2 days ago. The nurse
recognizes that which symptoms are suggestive of postpartum depression?
fatigue, insomnia, flat affect, and bouts of crying are symptoms that are
commonly seen in postpartum clients who are experiencing depression.
appropriate for gestational age.
(between the 10th and 90th percentile.)
A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the
60th percentile for weight. Based on the weight and gestational age of this newborn, the nurse should
classify this neonate as
During newborn assessment, a RN observes small white nodules on the roof of the newborn’s
mouth. This is a characteristic of which conditions?
are dark areas observed in dark-skinned newborns,
is a transient maculopapular rash seen in newborns.
are small white bumps that occur
on the nose due to clogged sebaceous glands.
A nurse is caring for a newborn following a spontaneous vaginal delivery. Five minutes after birth, the
newborn’s heart rate is 90/min. Which of the following Apgar heart rate scores should the newborn
A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should
perform which of the following?
Hold the newborn in a semi-sitting position, then allow the newborn’s head and
trunk to fall backward.
Clapping hands will elicit the
Stimulating the pads of the newborn’s hands will elicit the
outer lateral portion of the newborn’s soles will elicit a
What signs pertaining to respirations indicate that a newborn is having no
difficulty adapting to extrauterine life?
Normal resp rate for a newborn increases from 30-60/min w/ short periods of
apnea (< 15 seconds) occurring most frequently during the
(REM) sleep cycle. Periods of apnea lasting < 15 seconds are normal. Newborns
are obligatory nose breathers.
Grunting and nasal flaring
are signs of respiratory distress.
Crackles and wheezing are
symptoms of fluid or infection in the lungs.
A nurse is preparing to bathe a newborn and notices a bluish marking across the newborn’s lower
back. The nurse should understand that this mark is
frequently seen in newborns who have dark skin.
Mongolian spots are commonly found over the lumbosacral area of newborns who
have dark skin and are of African-American, Asian, or Native-American origin.
would be present as jaundice.
A nurse is preparing to administer prophylactic eye ointment into the eyes of a newborn to
treat ophthalmia neonatorum. Which of the following medications should the nurse anticipate
A nurse is caring for a newborn who was born to a mother who is infected with hepatitis B. What
treatment should this newborn receive?
hepatitis B and the hepatitis B immuno globulin (HBIG) vaccines. Both should
be administered within 12 hr of birth. The hepatitis B vaccine induces protective antibodies
in newborns who receive the recommended three doses.
A newborn was not dried completely after delivery. The nurse understands that which of the
following mechanisms causes the newborn to lose heat?
Evaporation is the loss of heat that occurs when a liquid is converted to a vapor. In a
newborn, heat loss by evaporation occurs as a result of vaporization of the moisture from
is the loss of heat from the body surface area to cooler surfaces that the
newborn may be in contact with.
is the flow of heat from the body surface area
to cooler air.
is the loss of heat to a cooler surface that is not in direct contact with
When performing nursing care for a newborn after birth, which of the following nursing
interventions is the highest priority?
The greatest risk to the newborn is cold stress. Therefore the highest priority intervention
is to prevent heat loss. Covering a newborn’s head with a cap prevents cold stress due to
excessive evaporative heat loss.
“Vitamin K assists with blood clotting.”
A nurse is preparing to administer a vitamin K (Aquamephyton) injection to a newborn. Which of
the following is an appropriate response by the nurse to the newborn’s mother regarding why this
medication is given?
Match the mother’s identification band with the newborn’s.
Which of the following actions should a nurse take when bringing a newborn to a mother for
breastfeeding for security purposes?
Why is it important that the newborn breastfeed and receive colostrum?
Colostrum is secreted during days 1 to 3 and contains the IgA immunoglobulin that provides
passive immunity to the newborn.
The mother asks the nurse, “How can I tell if my baby is receiving enough to eat?” What should the
nurse tell the mother?
A newborn is receiving adequate nutrition if he is content between feedings, gains weight,
and has 6 to 8 wet diapers/day.
How often should the newborn be burped during breastfeeding?
A newborn should be burped when alternating breasts.
A RN is giving instructions to a mother about how to breastfeed her newborn. Which action by the mother indicates the need for additional teaching?
The mother places a breast shield over her nipple before placing the nipple in
the newborn’s mouth.
A breast shield isn't routinely used for breastfeeding. A breast shield is worn when the
nipples r flat/inverted, or when they are sore/cracked.
A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which instructions should the nurse provide?
always keep the nipple full of formula to prevent the newborn from sucking in
air during the feeding. The newborn should be burped after each ½ oz, and he should be
cradled in a semi-upright position. Any unused formula should be discarded.
The mother places the newborn in a supine position during feeding.
4 hrs after admission to the nursery a newborn is taken to his mother for his 1st feeding. The
mother wants to bottle feed. The RN educates on bottle feeding.
Which observations by the nurse indicates that the mother needs additional
The newborn should not be placed in the supine position because of the danger of
Newborns who are bottle feeding do best when they are held close and at a 45˚
angle. All other techniques are correct for bottle feeding the newborn.
A mother asks why it is important to keep the nipple full of formula when bottle feeding. The RN
the newborn from swallowing air.
What percentage of a newborn’s birth weight is expected to be lost during the first 24 hr?
The normal weight loss after birth is 5 to 10%. All newborns should lose some weight after
birth due to fluid loss.
What is the single most important nursing measure that should be done to prevent newborn
Hand hygiene is the most important nursing intervention to prevent infection. The
nurse must engage in a 3-5min scrub from elbow to finger tips b4 entering the
nursery and thereafter. Hands should be washed b4 & after contact w/ the newborn.
When teaching parent’s about how to care for their newborn’s umbilical cord, a nurse should include
which of the following nursing interventions?
Keeping the newborn’s cord dry and clean helps reduce infection and hastens drying.
A parent has been given info about care of a newborn following circumcision. Which statement by the parent indicates a need for further teaching?
“I will give him a tub bath within a couple of days.”
A tub bath should not be given until the circumcision is completely healed.
Observe the newborn for bleeding by conducting checks every 15 min for 1 hr and then
every hour for at least 12 hr.
A nurse is aware that which of the following is a contraindication for circumcising a male newborn?
In hypospadias & epispadias, the urethra is located somewhere other than the tip of the
urethra, and the foreskin is needed for plastic surgery to repair the defect. Family Hx of
hemophilia, hypospadias, and epispadias are all contraindications.
A newborn has just been circumcised using a Gomco procedure. Which nursing
intervention is part of the initial care for this newborn?
Apply petroleum gauze to the site for 24 hr
to prevent the skin edges from sticking to the
When providing teaching about car seat safety to the parents of a newborn, the RN should instruct the parents to restrain the newborn in a car seat
in the back seat in a semi-reclined, rear-facing position.
**Infants who weigh up to 9.1 kg (20 lb) should be restrained in a car seat in a semi-reclined,
rear-facing position in the back seat of the car.
“My baby’s mouth should be suctioned before her nose."
to prevent aspiration during the gasp response.
Which of the following statements made by the parent of a newborn indicates a good understanding
of how to use a bulb syringe to suction excess mucus from the newborn’s airway?
large head in comparison to the body,
lanugo over the body, a weak grasp reflex, and skin that is thin, smooth, shiny, and possibly
a newborn who was born at 32wks gestation. his birth weight is 1,100g. His Apgar scores are 3 at 1min and 7 at 5min. He's experiencing nasal flaring, grunting, & intercostal retractions. What characteristics does the nurse may see at this birth?
Which assessment findings in a newborn who was born at 32 weeks of gestation
should indicate that a complication may be developing?
Nasal flaring, grunting, and substernal and intercostal retractions indicate that the infant is
experiencing respiratory distress.
Discuss why a preterm infant is at risk for ineffective thermoregulation? The infant’s low birth weight and gestational age means that
the infant has little glycogen
stored in his liver and little brown fat available for producing heat. He
lacks subcutaneous fat to insulate his body and his flaccid muscle tone does not
allow him to take a flexed position to prevent heat loss.
A nurse is examining an infant who was just delivered at 41 weeks of gestation. Which characteristics indicates that this infant is postterm?
Leathery, cracked, and wrinkled skin is seen in a newborn who is postterm due to placental
Abundant lanugo, flat areolas without breast buds, and heels that are movable
fully to the ears are
The infant is at term (40 weeks) and LGA (greater than the 90th percentile in weight).
newborn 40 weeks gestation.
a forceps-assisted birth was necessary. The newborn
weighs 9lb, 8oz. The newborn has marked caput succedaneum and marked bruising about
the face, head, and shoulders. How should the nurse characterize this infant?
A nurse is caring for an infant who has a high bilirubin level & is receiving phototherapy. Which findings in the newborn is the highest priority?
Infants receiving phototherapy are at greatest risk for dehydration related to loss of water
from frequent loose stools due to increased bilirubin excretion.
Surfactant therapy stabilizes the alveoli and prevents collapse, thereby increasing lung
compliance and maintaining or improving oxygen saturation
A nurse is caring for an infant who is preterm and has respiratory distress syndrome (RDS). Which
of the following assessment findings will assist the nurse in evaluating the efficacy of synthetic
A nurse should consider the possibility of neonatal withdrawal syndrome if a newborn
Symptoms of withdrawal from maternal substance abuse include CNS disturbances such as
an excessive or continuous high-pitched cry and a markedly hyperactive Moro reflex.
signs that can only be explained by pregnancy.
Fetal heart sounds
Visualization of fetus by ultrasoundFetal movement palpated by an experienced examiner
Presumptive signs – changes experienced by the woman that make her think
that she may be pregnant: Amenorrhea, fatigue, N/V,
Breast changes – Darkened areola, enlarged Montgomery’s tubules,
Quickening – slight fluttering movements of the fetus felt by a woman, usually
between 16 to 20 weeks of gestation.
Linea Nigra, Chloasma (mask of pregnancy),Striae gravidarum
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