Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versi, Exams of Nursing

Download Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versi and more Exams Nursing in PDF only on Docsity! Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. Chapter 18: Maternal Physiologic Changes 1. A woman gave birth to an infant boy 10 hour*s ago. Where would the nurse expect to locate this woman’s fundus? a. One centimeter above the umbilicus ANS: A Within 12 hours after delivery fundus-approximately 1 cm above umbilicus. fundus descends about 1-2 cm every 24 hours. By 6th postpartum week-fundus normally halfway between symphysis pubis and umbilicus. 2. Which woman is most likely to experience strong afterpains? b. A woman who is a gravida 4, para 4-0-0-4 ANS: B Afterpains-more common in multiparous,with births in which uterus was greatly distended,in woman who experienced polyhydramnios or delivered large infant. Breastfeeding may cause afterpains to intensify. 3. A woman gave birth to a healthy infant boy 5 days ago. What type of lochia would the nurse expect to find when assessing this woman? d. Lochia serosa ANS: D Lochia serosa-blood, serum, leukocytes,tissue debris,around day 3 or 4 after childbirth. Lochia rubra-blood,decidual,trophoblastic debris;3 to 4 days and pales, becoming pink or brown.Lochia alba-after day 10,continue up to 6 wks 4. Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? c. Prolactin Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: C Prolactin-increase progressively throughout pregnancy. In breastfeed-remain elevated into 6th week after birth. Estrogen,progesterone -decrease markedly after expulsion of placenta,reach their lowest levels 1 week into postpartum period. Human placental lactogen levels decrease dramatically after expulsion of placenta. 5. Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is: c. Loss of increased blood volume associated with pregnancy. ANS: C Within 12 hours of birth women begin to lose excess tissue fluid.1st mechanism for reducing retained fluids-profuse diaphoresis-often occurs, especially at night, for 1st 2-3 days after childbirth. Postpartal diuresis-mechanism by which body rids itself of excess fluid. Diaphoresis,diuresis-referred to as reversal of water metabolism of pregnancy.Postpartal diuresis may be caused by removal of increased venous pressure in lower extremities. 6. 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: b. Excessive uterine bleeding. ANS: B Excessive bleeding-occur immediately after birth if bladder becomes distended because it pushes uterus up,to side,prevents it from contracting firmly.UTI- may result from overdistention of bladder,not most serious consequence.ruptured bladder may result from severely overdistended bladder.vaginal bleeding most likely would occur before bladder reaches this level of overdistention.Bladder distention may result from bladder wall atony. 7. The nurse caring for the postpartum woman understands that breast engorgement is caused by: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: D Offensive odor-indicates infection. Lochia flow should approximate heavy menstrual period for 1st 2 hrs,then steadily decrease. Less lochia-seen after cesarean births,increases with ambulation and breastfeeding. 15. Which description of postpartum restoration or healing times is accurate? b. Vaginal rugae reappear by 3 weeks postpartum. ANS: B Vaginal rugae reappear by 3 weeks postpartum;never as prominent as in nulliparous women.Cervix regains-form within days;cervical os may take longer.Most episiotomies take 2-3 weeks to heal. Hemorrhoids can take 6 wks to decrease in size. 16. With regard to postpartum ovarian function, nurses should be aware that: d. The first menstrual flow after childbirth usually is heavier than normal. ANS: D 1st flow-heavier,within 3 or 4 cycles-back to normal.Ovulation can occur within 1st mth, but for 70% of nonlactating women,returns within 12 wks after birth.Breastfeeding take longer to resume ovulation.many women ovulate before1st postpartum menstrual period, contraceptive needed discussed early in puerperium. 17. As relates to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: c. Fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium. ANS: C Excess fluid loss through other means occurs.Kidney function usually returns to normal in about 1mth.Diastasis recti abdominis-separation of muscles in abdominal wall; no effect on voiding reflex. Bladder tone-restored 5-7 days after childbirth. 18. Knowing that the condition of the new mother’s breasts will be affected by whether she is breastfeeding, nurses should be able to tell their clients all the following statements except: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. a. Breast tenderness is likely to persist for about a week after the start of lactation. ANS: A Breast tenderness- 24-48 hours after lactation begins. movable, noncancerous mass-filled milk sac.Colostrum-present for few days whether mother breastfeeds or not.mother who does not want to breastfeed should also avoid stimulating her nipples. 19. With regard to the postpartum changes and developments in a woman’s cardiovascular system, nurses should be aware that: b. Respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth. ANS: B Respirations-decrease to within normal prepregnancy range by 6- 8 weeks after birth.Stroke volume increases,cardiac output remains high for couple of days.heart rate,BP-return to normal quickly.Leukocytosis increases 10-12 days after childbirth,can obscure diagnosis of acute infections(false-negative results).hypercoagulable state increases risk of thromboembolism-after cesarean birth. 20. Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium? d. Headaches ANS: D Headaches -have number of causes, some of which deserve medical attention.Total or nearly total regression of varicosities-expected.Carpal tunnel syndrome-relieved ,when compression on median nerve lessened. Periodic numbness of fingers usually disappears after birth unless carrying baby aggravates condition. 21. Several changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed? Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. a. Nail brittleness Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. c. 300 to 500 mL Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. d. 500 to 1000 mL ANS: C, D average blood loss vaginal birth of single fetus from 300-500 mL (10% of blood volume).cesarean -500-1000 mL(15% to 30% of blood volume). During 1st few days after birth plasma volume decreases further as result diuresis.Pregnancy-induced hypervolemia (increase in blood volume of at least 35%) allows most women to tolerate considerable blood loss during childbirth. MATCHING: The physiologic changes that occur during the reversal of the processes of pregnancy are distinctive; however, they are normal. To provide care during this recovery period the nurse must synthesize knowledge regarding anticipated maternal changes and deviations from normal. Please match the vital signs finding that the postpartum nurse may encounter with the probable cause: 29. Puerperal sepsis- Elevated temperature at 36 hours postpartum (C) 30. Unusually high epidural or spinal block- Hypoventilation (E) 31. Dehydrating effects of labor- Elevated temperature within the first 24 hours (A) 32. Hypovolemia resulting from hemorrhage- Rapid pulse (B) 33. Excessive use of oxytocin- Hypertension (D) Chapter 19: Nursing Care of the Family during the Postpartum Period 1. A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, “I’m bleeding a lot.” The most likely cause of postpartum hemorrhage in this woman is: c. Uterine atony. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: C woman gave birthto macrosomic boy after Pitocin augmentation- uterine atony. Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in 1st hour after delivery of placenta,not most likely cause of hemorrhage.unrepaired vaginal lacerations may cause bleeding, they typically would occur in period immediately after birth.Puerperal infection can cause subinvolution,subsequent bleeding;would be detected 24 hours after delivery. 2. 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: d. Massage the woman’s fundus. ANS: D nurse should assess uterus for atony.Uterine tone must be established to prevent excessive blood loss.nurse may begin IV infusion to restore circulatory volume, but this would not 1st action.Blood pressure-not reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be 1st action.physician would be notified after nurse completes assessment of woman. 3. 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 tid, and a stool softener. What information is most closely correlated with these orders? d. The woman has an episiotomy. ANS: D These orders-typical interventions for woman who has had pisiotomy, lacerations, hemorrhoids. A multiparous classification is not an indication for these orders. vacuum-assisted birth may be used in conjunction with episiotomy, which would indicate these interventions. 4. The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data? a. Rubella vaccine should be given. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. d. The nurse. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: D In couplet care mother shares room with newborn,care with nurse educated in maternity and infant care. 13. Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to: d. Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood. ANS: D “Mothering the mother” is more process of encouraging,supporting woman in her new role. 14. Excessive blood loss after childbirth can have several causes; the most common is: c. Failure of the uterine muscle to contract firmly. ANS: C Uterine atony can best be thwarted by maintaining good uterine tone,preventing bladder distention.vaginal or vulvar hematomas, unpaired lacerations of vagina or cervix,retained placental fragments-possible causes of excessive blood loss,uterine muscle failure (uterine atony)-most common cause. 15. A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to: a. Improve the accuracy of blood loss estimation, which usually is a subjective assessment. ANS: A Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 16. Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is: d. Inserting a sterile catheter. ANS: D Invasive procedures usually-last to be tried, especially with so many other simple.easy methods available (water, peppermint vapors, pain medication). 17. If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid? c. Having the patient sit in a chair. ANS: C Sitting immobile in chair-not help.Bed exercise,prophylactic footwear may. TED hose,SCD boots-recommended.Bed exercises-flexing, extending,rotating feet, ankles,legs-useful.Positive Homans’ sign(calf muscle pain,warmth, redness,tenderness)-immediate attention. 18. As relates to rubella and Rh issues, nurses should be aware that: b. Women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination. ANS: B contraception for 1 month after vaccinated.live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immune globulin is administered intramuscularly;never be given to infant. Rh immune globulin suppresses immune system,therefore could thwart rubella vaccination. 19. Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. a. Mother Rh2-, baby Rh+ ANS: A 24. Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? d. Assist the patient in emptying her bladder. ANS: D Urinary retention may cause overdistention of urinary bladder,which lifts,displaces uterus. Nursing actions need to be implemented before notifying physician.important to evaluate blood pressure, pulse,lochia if bleeding continues; focus at this point in time is to assist patient in emptying her bladder. 25. When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is: b. Early and frequent ambulation. ANS: B Activity will aid movement of accumulated gas in GI tract. Rectal suppositories-helpful after distention occurs;not prevent it.Ambulation-best prevention. Carbonated beverages-increase distention. 26. The nurse caring for the postpartum woman understands that breast engorgement is caused by: d. Congestion of veins and lymphatics. ANS: D 27. Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security? Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. a. The mother should check the photo ID of any person who comes to her room. d. Parents should use caution when posting photos of their infant on the Internet. e. The mom should request that a second staff member verify the identity of any questionable person. ANS: A, D, E MATCHING : Much of a woman’s behavior during the postpartum period is strongly influenced by her cultural background. Nurses are likely to come into contact with women from many different countries and cultures. All cultures have developed safe and satisfying methods of caring for new mothers and babies. Please match the cultural norm with the nationality of origin. 28. Muslim countries- Will not eat pork or pork products (D) 29. Korean or other South East Asian countries.- Prefer not to give babies colostrum (A) 30. Chinese- Have an IUD inserted after the first child (E ) 31. Haitian- Take the placenta home to bury (C ) 32. Mexican- Eat only warm foods and hot drinks (B) Chapter 20: Transition to Parenthood 1. After giving birth to a healthy infant boy, a primiparous woman, 16 years old, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is Risk for impaired parenting related to deficient knowledge of newborn care. In planning for the woman’s discharge, what should the nurse be certain to include in the plan of care? Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. d. Provide time for the patient to bathe her infant after she views an infant bath demonstration. ANS: D 2. The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, would the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? b. Seldom makes eye contact with her son ANS: B woman should be encouraged to hold her infant in en face position and make eye contact with infant. Normal infant-parent interactions include talking,cooing to her son, cuddling her son close to her, and telling visitors how well her son is feeding. 3. The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to: b. Show the mother how the infant initiates interaction and pays attention to her. ANS: B Pointing out responsiveness of infant-positive strategy for facilitating parent- infant attachment.Videos-educational tool that can demonstrate parent-infant attachment. 4. The nurse hears a primiparous woman talking to her son and telling him that his chin is just like his dad’s chin. This woman’s statement reflects: c. Claiming. ANS: C Claiming-process by which child identified in terms of likeness to other Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 8. The nurse notes that a Vietnamese woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In evaluating the woman’s behavior with her infant, the nurse realizes that: a. What appears to be a lack of interest in the newborn is in fact the Vietnamese way of demonstrating intense love by attempting to ward off evil spirits. ANS: A 9. Many first-time parents do not plan on their parents’ help immediately after the newborn arrives. What statement by the nurse is the most appropriate when counseling new parents about the involvement of grandparents? b. “Grandparents can help you with parenting skills and also help preserve family traditions.” ANS: B 10. When the infant’s behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, this is called: a. Mutuality. ANS: A 11. In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. Which one is a facilitating behavior? b. The parents hover around the infant, directing attention to and pointing at the infant. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: B Hovering over infant,obviously paying attention to baby-facilitating behaviors. Inhibiting behaviors-difficulty naming infant, making no effort to interpret actions or needs of infant,not moving from fingertip touch to palmar contact, holding. 12. With regard to parents’ early and extended contact with their infant and the relationships built, nurses should be aware that: c. Extended contact is especially important for adolescents and low-income women because they are at risk for parenting inadequacies. ANS: C 13. In the United States the en face position is preferred immediately after birth. Nurses can facilitate this process by all of these actions except: a. Washing both the infant’s face and the mother’s face. ANS: A To facilitate position in which parent’s and infant’s faces-approximately 8 inches apart on same plane, allowing them to make eye contact, nurse can place infant at proper height on mother’s body dim light so that infant’s eyes open, delay putting ointment in infant’s eyes. 14. Other early sensual contacts between infant and mother involve sound and smell. Nurses should be aware that, despite what folk wisdom may say: b. Infants can learn to distinguish their mother’s voice from others soon after birth. ANS: B Infants know sound of mother’s voice early;respond positively to high-pitched voices; unique odor;quickly learn to distinguish odor of their mother’s breast milk. 15. After they are born, a crying infant may be soothed by being held in a position in which the newborn can hear the mother’s heartbeat. This phenomenon is known as: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. d. Biorhythmicity. ANS: D newborn in rhythm with mother;develops personal biorhythm with parents’ help over time.Entrainment-movement of newborns in time to structure of adult speech.Reciprocity-body movement or behavior that gives cues to person’s desires;take several weeks to develop with new baby. Synchrony-fit between infant’s behavioral cues and parent’s responses. 16. Of the many factors that influence parental responses, nurses should be conscious of negative stereotypes that apply to specific patient populations. Which response could be an inappropriate stereotype of adolescent mothers? c. Adolescent mothers have a higher documented incidence of child abuse. ANS: C 17. When working with parents who have some form of sensory impairment, nurses should understand that is an inaccurate statement. b. Visually impaired mothers cannot overcome the infant’s need for eye-to- eye contact. ANS: B Other sensory output can be provided by parent, other people can participate,other coping devices can be used. Internet-teaching tool for deaf:videos with subtitles or nurses signing.electronic devices can turn sound into light flashes to help pick up child’s cry. 18. With regard to the adaptation of other family members, mainly siblings and grandparents, to the newborn, nurses should be aware that: b. Participation in preparation classes helps both siblings and grandparents. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 22. The postpartum woman who continually repeats the story of her labor, delivery, and recovery experience is: b. Making the birth experience “real.” ANS: B Reliving birth experience makes event real,helps realize that pregnancy is over,that infant is born, now separate individual. new mother is in taking-in phase, trying to make birth experience seem real,separate the infant from herself. 23. On observing a woman on her first postpartum day sitting in bed while her newborn lies awake in the bassinet, the nurse should: c. Hand the baby to the woman. ANS: C “taking-in” phase of maternal adaptation (mother may be passive and dependent)nurse should encourage bonding when infant is in quiet alert stage;done simply giving baby to mother. 24. A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old brother is punching his mother on the back. The nurse should: d. Realize that this is a normal family adjusting to family change. ANS: D 25. The best way for the nurse to promote and support the maternal-infant bonding process is to: c. Assist the family with rooming-in. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: C Close,frequent interaction between mother and infant, which facilitated by rooming-in, important in bonding process-mother-baby care or couplet care. 26. During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting go ANS: A Accepting real infant,relinquishing fantasy infant-letting-go phase of maternal adjustment.taking-hold phase mother assumes responsibility for her own care,shifts her attention to infant. taking-in phase-primarily focused on her own needs. 27. A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry. Your initial action should be to d. Allow her time to express her feelings. ANS: D 28. A man calls the nurse’s station and states that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, “She was never like this before the baby was born.” The nurse’s initial response could be to: b. Reassure him that this behavior is normal. ANS: B 29. To promote bonding and attachment immediately after delivery, the most important nursing intervention is to: b. Assist the mother in assuming an en face position with her newborn. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: B 30. A new father states, “I know nothing about babies,” but he seems to be interested in learning. This is an ideal opportunity for the nurse to: d. Include him in teaching sessions. ANS: D 31. Which concerns about parenthood are often expressed by visually impaired mothers (Select all that apply)? a. Infant safety b. Transportation d. Missing out visually e. Needing extra time for parenting activities to accommodate the visual limitations ANS: A, B, D, E 32. A parent who has a hearing impairment is presented with a number of challenges in parenting. Which nursing approaches are appropriate for working with hearing- impaired new parents (Select all that apply)? a. Use devices that transform sound into light. d. Ascertain whether the patient can read lips before teaching. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. site. ANS: A Late PPH-subinvolution of uterus,pelvic infection,retained placental fragments.Late PPH not typically result of defective vascularity of decidua, cervical lacerations, coagulation disorders. 4. Which woman is at greatest risk for early postpartum hemorrhage (PPH)? b. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced ANS: B 5. The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to: c. Palpate the uterus and massage it if it is boggy. ANS: C 6. When caring for a postpartum woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is: d. Urinary output of at least 30 mL/hr. ANS: D 7. One of the first symptoms of puerperal infection to assess for in the postpartum woman is: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. d. Temperature of 38° C (100.4° F) or higher on 2 successive days Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. starting 24 hours after birth. ANS: D 8. The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by: b. Using proper breastfeeding techniques. ANS: B 9. Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance: d. Traditionally PPH has been classified as early or late with respect to birth. ANS: D 10. A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect and should confirm the diagnosis by . c. Thrombophlebitis; using real-time and color Doppler ultrasound ANS: C Doppler ultrasound is a common noninvasive way to confirm diagnosis. 11. What PPH conditions are considered medical emergencies that require immediate treatment? Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 19. To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) without psychotic features: c. Is distinguished by irritability, severe anxiety, and panic attacks. ANS: C PPD -spontaneous crying long after usual duration of baby blues. It is more common among younger mothers,African-American mothers. 20. To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) with psychotic features: d. May include bipolar disorder (formerly called “manic depression”). ANS: D 21. With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or postpartum depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent postpartum depression. The most accurate statement as related to these activities is to: d. Realize that this is a common occurrence that affects many women. ANS: D 22. A newborn in the neonatal intensive care unit (NICU) is dying as a result of a massive infection. The parents speak to the neonatologist, who informs them of their son’s prognosis. When the father sees his son, he says, “He looks just fine to me. I can’t understand what all this is about.” The most appropriate response by the nurse would be: b. “This must be a difficult time for you. Tell me how you’re doing.” Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: B 23. After giving birth to a stillborn infant, the woman turns to the nurse and says, “I just finished painting the baby’s room. Do you think that caused my baby to die?” The nurse’s best response to this woman is: d. “I can understand your need to find an answer to what caused this. What else are you thinking about?” ANS: D 24. Which options for saying goodbye would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? c. “When your baby is born, would you like to see and hold her?” ANS: C 25. A woman experienced a miscarriage at 10 weeks of gestation and had a dilation and curettage (D&C). She states that she is just fine and wants to go home as soon as possible. While you are assessing her responses to her loss, she tells you that she had purchased some baby things and had picked out a name. On the basis of your assessment of her responses, what nursing intervention would you use first? d. Ask her what name she had picked out for her baby. ANS: D 26. A woman is diagnosed with having a stillborn. At first, she appears stunned by the news, cries a little, and then asks you to call her mother. The phase of bereavement the woman is experiencing is called: a. Anticipatory grief. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: B 27. During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. The nurse’s role should be to: c. Make sure the parents themselves approve the final decisions. ANS: C 28. The nurse caring for a family during a loss may notice that survival guilt sometimes is felt at the death of an infant by the child’s: d. Grandparents. ANS: D Survival guilt- grandparents because they believe that death upsets natural order of things. angry that they are alive and their grandchild is not. 29. Complicated bereavement: c. Is an extremely intense grief reaction that persists for a long time. ANS: C 30. Early postpartum hemorrhage is defined as a blood loss greater than: a. 500 mL in the first 24 hours after vaginal delivery. ANS: A 31. A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she “feels all wet underneath.” You discover Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. c. The organisms that cause mastitis are not passed to the milk. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: C 36. Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? d. Postpartum blues ANS: D 37. Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is: c. Post-traumatic stress disorder (PTSD). ANS: C 38. Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply): a. Pitocin. d. Hemabate. b. Methergine. ANS: A, B, D Pitocin, Methergine, Hemabate -manage PPH. Terbutaline,magnesium sulfate are tocolytics; relaxation of uterus causes or worsens PPH. 39. Possible alternative and complementary therapies for postpartum depression (PPD) for breastfeeding mothers include (Select all that apply): Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. a. Acupressure. b. Aromatherapy. e. Yoga. ANS: A, B, E Possible alternative/complementary therapies for postpartum depression:acupuncture, acupressure, aromatherapy, therapeutic touch, massage, relaxation techniques, reflexology, yoga. MATCHING : PPH may be sudden and result in rapid blood loss. The nurse must be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss. Astute assessment of circulatory status can be done with noninvasive monitoring. Please match the type of noninvasive assessment that the RN would perform with the appropriate clinical manifestation or body system. 40. Pulse oximetry- Measurement (E ) 41. Heart sounds- Auscultation ( B) 42. Arterial pulses- Palpation (A) 43. Skin color, temperature, turgor- Inspection (C ) 44. Presence or absence of anxiety-Observation (D ) Chapter 22: Physiologic and Behavioral Adaptations of the Newborn 1. A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: b. First period of reactivity. ANS: B Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. c. Hip dysplasia. ANS: C 7. A new mother states that her infant must be cold because the baby’s hands and feet are blue. The nurse explains that this is a common and temporary condition called: a. Acrocyanosis. ANS: A 8. The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: d. Initiation and maintenance of respirations. ANS: D 9. The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them: b. “Infants can track their parent’s eyes and distinguish patterns; they prefer complex patterns.” ANS: B 10. While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a “C” with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. d. Moro reflex. ANS: D 11. While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should: c. Document the finding as erythema toxicum. ANS: C 12. A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on “high.” The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse’s best response is: a. “Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.” ANS: A 13. A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, “What is this black, sticky stuff in her diaper?” The nurse’s best response is: a. “That’s meconium, which is your baby’s first stool. It’s normal.” ANS: A 14. The transition period between intrauterine and extrauterine existence for the newborn: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. b. Lasts from birth to day 28 of life. ANS: B 15. Which statement describing the first phase of the transition period is inaccurate? d. It may involve the infant’s suddenly sleeping briefly. ANS: D 16. With regard to the respiratory development of the newborn, nurses should be aware that: a. The first gasping breath is an exaggerated respiratory reaction within 1 minute of birth. ANS: A 17. With regard to the newborn’s developing cardiovascular system, nurses should be aware that: c. The point of maximal impulse (PMI) often is visible on the chest wall. ANS: C 18. By knowing about variations in infants’ blood count, nurses can explain to their clients that: b. The early high white blood cell (WBC) count is normal at birth and should decrease rapidly. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 28. During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is not one of these essential factors? d. Psychologic ANS: D 29. A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: a. May occur with spontaneous vaginal birth. ANS: A 30. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth. ANS: D 31. Nurses can prevent evaporative heat loss in the newborn by: a. Drying the baby after birth and wrapping the baby in a dry blanket. ANS: A Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 32. A first-time dad is concerned that his 3-day-old daughter’s skin looks “yellow.” In the nurse’s explanation of physiologic jaundice, what fact should be included? c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. ANS: C 33. Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: b. Increased pressure in the left atrium. ANS: B 34. The nurse should immediately alert the physician when: a. The infant is dusky and turns cyanotic when crying. ANS: A 35. While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: c. 120 to 160 beats/min. ANS: C 36. In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. c. Not initially synthesized because of a sterile bowel at birth. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. b. As the skin dries, the creases will become more prominent. ANS: B 42. What are modes of heat loss in the newborn (Select all that apply)? b. Convection c. Radiation d. Conduction ANS: B, C, D MATCHING: The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. 43. Signs of stress related to homeostatic adjustment- Autonomic stability(D) 44. Ability to respond to discrete stimuli while asleep- Habituation(A) 45. Measure of general arousability- Range of state (C ) 46. How the infant responds when aroused- Regulation of state (E ) 47. Ability to attend to visual and auditory stimuli while alert- Orientation (B ) Chapter 23: Nursing Care of the Newborn and Family Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 1. An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed: c. At least twice, 1 minute and 5 minutes after birth. ANS: C 2. A new father wants to know what medication was put into his infant’s eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to: b. Prevent gonorrheal and chlamydial infection of the infant’s eyes potentially acquired from the birth canal. ANS: B 3. The nurse is using the 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 ANS: A 4. A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant’s parents should be based on the knowledge that petechiae: a. Are benign if they disappear within 48 hours of birth. ANS: A Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 5. A newborn is jaundiced and 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: c. Place eye shields over the newborn’s closed eyes. ANS: C 6. Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after: d. The infant voids. ANS: D 7. A mother expresses fear about changing her infant’s diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? c. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. ANS: C 8. When preparing to administer a hepatitis B vaccine to a newborn, the nurse should: a. Obtain a syringe with a 25-gauge, 5/8-inch needle. ANS: A 9. The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: A 14. In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would: c. Fall between the 10th and 90th percentiles for the infant’s age. ANS: C 15. During the complete physical examination 24 hours after birth: b. The nurse can gauge the neonate’s maturity level by assessing the infant’s general appearance. ANS: B 16. As related to laboratory tests and diagnostic tests in the hospital after birth, nurses should be aware that: c. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. ANS: C 17. Nurses can assist parents who are trying to decide whether their son should be circumcised by explaining: a. The pros and cons of the procedure during the prenatal period. ANS: A 18. As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Which statement is incorrect? Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. d. Place the infant on his or her abdomen to sleep. ANS: D 19. The normal term infant has little difficulty clearing the airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to: c. Suction the mouth first. ANS: C 20. When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to: d. Recognize and treat newborn disorders early. ANS: D 21. To prevent the abduction of newborns from the hospital, the nurse should: b. Apply an electronic and identification bracelet to mother and infant. ANS: B 22. The nurse administers vitamin K to the newborn for which reason? c. Bacteria that synthesize vitamin K are not present in the newborn’s intestinal tract. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: C 23. 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. ANS: A 24. Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain management techniques include (Select all that apply): a. Swaddling. b. Nonnutritive sucking. c. Skin-to-skin contact with the mother. d. Sucrose. ANS: A, B, C, D 25. 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 American Academy of Pediatrics. Reasons for having this testing performed include (Select all that apply): a. Prevention or reduction of developmental delay. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 7. At a 2-month well-baby examination, it was discovered that a breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse agree that, to gain weight faster, the infant needs to: c. Add at least one extra breastfeeding session every 24 hours. ANS: C 8. A new mother wants to be sure that she is meeting her daughter’s needs while feeding her commercially prepared infant formula. The nurse should evaluate the mother’s knowledge about appropriate infant care. The mother meets her child’s needs when she: c. Burps her infant during and after the feeding as needed. ANS: C 9. The nurse is discussing storage of breast milk with a mother whose infant is preterm and in the special care unit. What statement would indicate that the mother needs additional teaching? a. “I can store my breast milk in the refrigerator for 3 months.” ANS: A 10. According to the recommendations of the American Academy of Pediatrics on infant nutrition: a. Infants should be given only human milk for the first 6 months of life. ANS: A Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 11. According to demographic research, the woman least likely to breastfeed and therefore most likely to need education regarding the benefits and proper techniques of breastfeeding would be: c. A woman who is younger than 25 years of age, African-American, and employed full time outside the home. ANS: C 12. Which statement concerning the benefits or limitations of breastfeeding is inaccurate? d. Breastfeeding increases the risk of childhood obesity. ANS: D 13. The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would be inaccurate and provide conflicting information to the patient? b. Breastfeeding is an effective method of birth control. ANS: B 14. While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the patient accordingly. Which statement as part of this discussion would be incorrect? c. Breastfeeding costs employers in terms of time lost from work. ANS: C Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 15. The best reason for recommending formula over breastfeeding is that: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: B 24. A newly delivered mother who intends to breastfeed tells her nurse, “I am so relieved that this pregnancy is over so I can start smoking again.” The nurse encourages the client to refrain from smoking. However, this new mother insists that she will resume smoking. The nurse will need to adapt her health teaching to ensure that the client is aware that: d. The mother should always smoke in another room. ANS: D 25. Which type of formula is not diluted before being administered to an infant? c. Ready-to-use ANS: C 26. How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day? c. 95 to 110 ANS: C 27. The hormone necessary for milk production is: b. Prolactin. ANS: B 28. To initiate the milk ejection reflex (MER), the mother should be advised to: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. c. Place the infant to the breast. ANS: C 29. As the nurse assists a new mother with breastfeeding, the client asks, “If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?” The nurse’s best response is that it contains: c. Important immunoglobulins. ANS: C 30. When responding to the question “Will I produce enough milk for my baby as she grows and needs more milk at each feeding?” the nurse should explain that: d. The mother’s milk supply will increase as the infant demands more at each feeding. ANS: D 31. To prevent nipple trauma, the nurse should instruct the new mother to: b. Position the infant so the nipple is far back in the mouth. ANS: B 32. Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them about pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? a. A premature infant more easily digests breast milk than formula. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: A 33. A new mother asks whether she should feed her newborn colostrum, because it is not “real milk.” The nurse’s most appropriate answer is: a. Colostrum is high in antibodies, protein, vitamins, and minerals. ANS: A 34. All parents are entitled to a birthing environment in which breastfeeding is promoted and supported. The Baby Friendly Hospital Initiative endorsed by WHO and UNICEF was founded to encourage institutions to offer optimal levels of care for lactating mothers. Which instruction is not included in the “Ten Steps to Successful Breastfeeding for Hospitals”? d. Give artificial teats or pacifiers as necessary. ANS: D 35. Examples of appropriate techniques to wake a sleepy infant for breastfeeding include (Select all that apply): a. Unwrapping the infant. b. Changing the diaper. c. Talking to the infant. Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 1. A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse’s most appropriate action is to: d. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia. ANS: D 2. Infants of mothers with diabetes (IDMs) are at higher risk for developing: c. Respiratory distress syndrome. ANS: C .IDMs are at risk for macrosomia, birth injury, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia,polycythemia 3. An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: c. Hypoglycemia. ANS: C 4. When assessing the preterm infant the nurse understands that compared with the term infant, the preterm infant has: d. Greater surface area in proportion to weight. ANS: D Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 5. On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask whether they can hold their infant during his next gavage feeding. Given that this newborn is physiologically stable, what response would the nurse give? d. “You may hold your baby during the feeding.” ANS: D 6. A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents? a. “Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide.” ANS: A 7. When providing an infant with a gavage feeding, which of the following should be documented each time? d. The infant’s response to the feeding ANS: D 8. An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? c. Slow, small, warm bolus feedings over 30 minutes ANS: C Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. 9. An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse’s most appropriate action would be to: a. Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. ANS: A 10. A newborn was admitted to the neonatal intensive care unit after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborn’s parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurse’s most appropriate action would be to: b. Go to the parents, introduce himself or herself, and gently encourage the parents to come meet their infant; explain the equipment first, and then focus on the newborn. ANS: B 11. Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: b. Abdominal distention, temperature instability, and grossly bloody stools. ANS: B 12. An infant is being discharged from the neonatal intensive care unit after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. ANS: A 16. Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are: d. Breathing in a respiratory pattern common to premature infants. ANS: D 17. The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant’s gestational age. This intervention: c. Helps infants to interact directly with their parents and enhances their temperature regulation. ANS: C 18. For clinical purposes, preterm and post-term infants are defined as: c. Preterm before 37 weeks, and post-term beyond 42 weeks, no matter the size for gestational age at birth. ANS: C 19. With regard to small for gestational age (SGA) infants and intrauterine growth restrictions (IUGR), nurses should be aware that: b. Infants with asymmetric IUGR have the potential for normal growth and development. ANS: B 20. As related to the eventual discharge of the high risk newborn or transfer to a Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. different facility, nurses and families should be aware that: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. a. Infants will stay in the neonatal intensive care unit (NICU) until they are ready to go home. ANS: C 21. Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC: b. Breastfeeding ANS: B 22. As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits: c. Mottled skin with acrocyanosis. ANS: C 23. Because of the premature infant’s decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? d. Risk for infection Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. c. Swaddling the infant snugly and holding the baby tightly. ANS: C 28. Human immunodeficiency virus (HIV) may be perinatally transmitted: d. Through the ingestion of breast milk from an infected mother. ANS: D 29. The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States? a. Alcohol ANS: A 30. During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurse’s best response would be: a. “Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child.” ANS: A 31. A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant’s eyes when the mother asks, “What is that medicine for?” The nurse responds: c. “Erythromycin is given prophylactically to prevent a gonorrheal Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. infection.” ANS: C 32. With regard to injuries to the infant’s plexus during labor and birth, nurses should be aware that: a. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. ANS: A 33. As related to central nervous system injuries that could occur to the infant during labor and birth, nurses should be aware that: c. In many infants signs of hemorrhage in a full-term infant are absent and are diagnosed only through laboratory tests. ANS: C 34. To care adequately for infants at risk for neonatal bacterial infection, nurses should be aware that: b. Nosocomial infection can be prevented by effective handwashing; early- onset infections cannot. ANS: B 35. Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. c. Congenital syphilis. ANS: C 36. What bacterial infection is definitely decreasing because of effective drug treatment? d. Group B streptococcal infection ANS: D 37. In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: c. Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. ANS: C 38. A careful review of the literature on the various recreational and illicit drugs reveals that: a. More longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs. ANS: A 40. Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. d. PCP. ANS: A, B, C, D 49. Risk factors associated with necrotizing enterocolitis (NEC) include (Select all that apply): a. Polycythemia. b. Anemia. c. Congenital heart disease. ANS: A, B, C 50. Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for (Select all that apply): a. Problems with thermoregulation c. Hyperbilirubinemia d. Sepsis ANS: A, C, D . Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. MATCHING :Car seat safety is an essential part of discharge planning, and infants younger than 37 weeks of gestation should have a period of observation in an appropriate car seat to monitor for possible apnea, bradycardia, and decreased SaO2. The nurse who is about to perform a car seat evaluation on a late-preterm infant will perform the sequence of the test in which order? 51. Step 1- Use the parent’s car seat.(F) 52. Step 2- Perform the evaluation 1 to 7 days before discharge.(E) 53. Step 3- Secure the infant in the car seat per guidelines using blanket rolls on the side.(A) 54. Step 4- Set the pulse oximeter low alarm at 88%.(G) 55. Step 5- Set the heart rate alarm at 80 bpm and the apnea alarm at 20 seconds. ( C) 56. Step 6-Leave the infant undisturbed for 90 to 120 minutes.(B) 57. Step 7- Document the infant’s tolerance to the test.(D) Chapter 13: Labor and Birth Processes 1. A new mother asks the nurse when the “soft spot” on her son’s head will go away. The nurse’s answer is based on the knowledge that the anterior fontanel closes after birth by months. d. 18 ANS: D 2 fontanels:anterior fontanel, closes by 18 months after birth. 2. When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal: c. Attitude. ANS: C Attitude -relation of fetal body parts to one another. Lie-relation of long axis Chapter 18: Maternal Physiologic Changes Examination Study Guide 2023 Latest Updated versions. (spine) of fetus to long axis (spine) of mother. Presentation-part of fetus that enters