Exam Review

A nurse is observing the breathing pattern of a full-term newborn as part of the health assessment. A full-term newborn's breathing pattern is predominantly:
A)Diaphragmatic with chest retraction.
B)Deep with a regular rhythm.
C)Chest breathing with nasal flaring.
D)Abdominal with synchronous chest movements.
A nurse is reassuring new parents whose infant develops caput succedaneum. It is important that the nurse is aware that this condition:
A)Only happens as the result of a forceps or vacuum delivery.
B)Will gradually absorb over the first few months of life.
C)Will increase the risk for jaundice due to bleeding under the periosteum.
D)May occur with spontaneous vaginal birth as a result of the pressure against the maternal bony pelvis.
An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment which includes the Apgar score. The Apgar assessment is performed:
A)At least twice, 1 minute and 5 minutes after birth.
B)Every 15 minutes during the newborn's first hour after birth.
C)Once by the obstetrician, just after the birth.
D)Only if the newborn is in obvious distress.
The nurse administers vitamin K to the newborn for what reason?
A)Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract, and it promotes normal clotting factors to develop sooner.
B)Most mothers have a diet deficient in vitamin K, which results in the infant being deficient.
C)Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection.
D)The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.

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Exam Review

A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:
A)Place eye shields over the newborn's closed eyes.
B)Change the newborn's position every 4 hours.
C)Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea.
D)Apply an oil-based lotion to the newborn's skin to prevent drying and cracking.
During discharge teaching, the nurse is educating the parents on how to protect the respiratory system for their newborn. During parent teach-back, which quote should prompt the nurse to intervene and reeducate the parents?
A)"The baby should not have loose bedding on their crib.”.
B)"Keep the infant away from secondhand smoke.”.
C)"Prevent exposure to people with upper respiratory tract infections.”.
D)"Have the baby sleep on his or her belly to prevent aspiration.”. —
A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who:
A)Has at least 4 wet diapers per day with the number increasing for each day of life during the first week.
B)Gains 1 to 2 ounces per week.
C)Sleeps for 6 hours at a time between feedings.
D)Has at least one breast milk stool every 24 hours.
A breastfeeding woman develops engorged breasts at 3 days postpartum. What action would help this woman achieve her goal of reducing the engorgement? The woman:
A)Reduces her fluid intake for 24 hours.
B)Uses her breast pump whenever she feels engorged.
C)Skips feedings to let her sore breasts rest.
D)Breastfeeds her infant every 2-3 hours.

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Exam Review

According to the recommendations of the American Academy of Pediatrics (AAP) on infant nutrition:
A)Infants fed on formula should be started on solid food sooner than breastfed infants.
B)If infants are weaned from breast milk before 12 months, they should receive cow's milk, not formula.
C)After 6 months, mothers should shift from breast milk to cow's milk.
D)Infants should be given only human milk for the first 6 months of life.
Benefits to the mother associated with breastfeeding include all except:
A)It reduces the risk of osteoporosis.
B)They have a decreased risk of breast cancer.
C)It is an effective method of birth control for up to 12 months.
D)It may enhance postpartum weight loss.
The best reason for recommending formula over breastfeeding is:
A)The mother sees bottle feeding as more convenient.
B)The mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk.
C)The mother lacks confidence in her ability to breastfeed.
D)Other family members or care providers also need to feed the baby.
With regard to the special qualities of human breast milk and milk production, nurses should be aware that:
A)Frequent feedings during predictable growth spurts stimulate increased milk production. This reinforces that supply meets demand.
B)Breast milk has more vitamin D and iron compared to formula.
C)The milk at the beginning of the feeding is the same as the milk at the end of the feeding.
D)Colostrum is an early, less concentrated, less rich version of mature milk.

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Exam Review

With regard to basic care of the breastfeeding mother, nurses should be able to advise her that she:
A)Will need an extra 1000 calories a day to maintain energy and produce milk.
B)Should avoid trying to lose large amounts of weight.
C)Must avoid exercising because it is too fatiguing.
D)Can go back to prepregnancy consumption patterns of any drinks as long as she gets enough calcium.
Which woman is most likely to experience strong afterpains?
A)A woman who experienced oligohydramnios.
B)A woman who has had three previous births.
C)A woman who is bottle feeding her infant.
D)A woman whose infant weighed 5 pounds, 3 ounces.
A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:
A)Excessive uterine bleeding.
B)A ruptured bladder.
C)Urinary tract infection.
D)Bladder wall atony.
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to:
A)Begin an intravenous (IV) infusion of Ringer's lactate solution.
B)Assess the woman's vital signs.
C)Call the woman's primary health care provider.
D)Massage the woman's fundus.

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Exam Review

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath, and a stool softener. What information is most closely correlated with these orders?
A)The woman received epidural anesthesia.
B)The woman has an episiotomy or a laceration of the perineum.
C)The woman is a gravida 2, para 2.
D)The woman had a vacuum-assisted birth.
A primiparous woman is to be discharged from the hospital tomorrow with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged?
A)The woman leaves the infant on her bed while she takes a shower.
B)The woman reads a magazine while her infant sleeps.
C)The woman changes her infant's diaper and then shows the nurse the contents of the diaper.
D)The woman continues to hold and cuddle her infant after she has fed her.
Which finding could prevent early discharge of a newborn who is now 12 hours old?
A)Voided, clear, pale urine three times since birth.
B)Birth weight of 3000 g.
C)Infant breastfed once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast.
D)One meconium stool since birth.
In the recovery room, if a woman is asked to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, she is most likely being tested to see whether she:
A)Has regained some flexibility.
B)Has hidden bleeding underneath her.
C)Is a candidate to go home after 6 hours.
D)Has recovered from epidural or spinal anesthesia.

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