Maternity Nursing Revised Reprint 8th Edition by Deitra Leonard – Test Bank

Complete Test Bank With Answers

 

 

 

Sample Questions Posted Below

 

 

 

 

Lowdermilk: Maternity Nursing, 8th Edition

 

Chapter 05: Genetics, Conception, and Fetal Development

 

Test Bank

 

MULTIPLE CHOICE

 

1. A father and mother are carriers of phenylketonuria (PKU). Their 2-year-old daughter has PKU. The couple tells the nurse that they are planning to have a second baby. Because their daughter has PKU, they are sure that their next baby won’t be affected. What response by the nurse is most accurate?

a.	“Good planning; you need to take advantage of the odds in your favor.”
b.	“I think you’d better check with your doctor first.”
c.	“You are both carriers, so each baby has a 25% chance of being affected.”
d.	“The ultrasound indicates a boy, and boys are not affected by PKU.”

 

ANS: C

 

	Feedback
A	This couple still has an increased likelihood of having a child with PKU. Having one child already with PKU does not guarantee that they will not have another.
B	These parents need to discuss their options with their physician. However, an opportune time has presented itself for the couple to receive correct teaching about inherited genetic risks.
C	The chance is one in four that each child produced by this couple will be affected by PKU disorder.
D	No correlation exists between gender and inheritance of the disorder, because PKU is an autosomal recessive disorder.

 

DIF:   Cognitive Level: Application        REF:  147

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

2. With regard to the structure and function of the placenta, the maternity nurse should be aware that:

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

 

ANS: B

 

	Feedback
A	The placenta widens until week 20 and continues to grow thicker.
B	The placenta produces four hormones necessary to maintain the pregnancy.
C	Toxic substances such as nicotine and carbon monoxide readily cross the placenta into the fetus.
D	Optimal circulation occurs when the woman is lying on her side.

 

DIF:   Cognitive Level: Comprehension  REF:  156

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

 

3. The nurse is providing genetic counseling for an expectant couple who already have a child with trisomy 18. The nurse should:

a.	Tell the couple they need to have an abortion within 2 to 3 weeks.
b.	Explain that the fetus has a 50% chance of having the disorder.
c.	Discuss options with the couple, including amniocentesis to determine whether the fetus is affected.
d.	Refer the couple to a psychologist for emotional support.

 

ANS: C

 

	Feedback
A	The couple should be given information about the likelihood of having another baby with this disorder so that they can make an informed decision.
B	A genetic counselor is the best source for determining genetic probability ratios.
C	Genetic testing, including amniocentesis, would need to be performed to determine whether the fetus is affected.
D	The couple eventually may need emotional support, but the status of the pregnancy must be determined first.

 

DIF:   Cognitive Level: Comprehension  REF:  144, 145

OBJ:  Client Needs: Physiologic Integrity

TOP:  Nursing Process: Planning, Implementation

 

4. In presenting to obstetric nurses interested in genetics, the genetic nurse identifies the primary risk(s) associated with genetic testing as:

a.	Anxiety and altered family relationships.
b.	Denial of insurance benefits.
c.	High false positives associated with genetic testing.
d.	Ethnic and socioeconomic disparity associated with genetic testing.

 

ANS: B

 

	Feedback
A	These factors may be difficulties associated with genetic testing, but they are not risks associated with testing.
B	Decisions about genetic testing are shaped by socioeconomic status and the ability to pay for the testing. Some types of genetic testing are expensive and are not covered by insurance benefits.
C	This factor may be a difficulty associated with genetic testing, but it is not a risk associated with testing.
D	This factor may be a difficulty associated with genetic testing, but it is not a risk associated with testing.

 

DIF:   Cognitive Level: Comprehension  REF:  142, 143

OBJ:  Client Needs: Health Promotion and Maintenance

TOP:  Nursing Process: Implementation

 

5. A woman’s cousin gave birth to an infant with a congenital heart anomaly. The woman asks the nurse when such anomalies occur during development. Which response by the nurse is most accurate?

a.	“We don’t really know when such defects occur.”
b.	“It depends on what caused the defect.”
c.	“They occur between the third and fifth weeks of development.”
d.	“They usually occur in the first 2 weeks of development.”

 

ANS: C

 

	Feedback
A	This is an inaccurate statement.
B	Regardless of the cause, the heart is vulnerable during its period of development, the third to fifth weeks.
C	The cardiovascular system is the first organ system to function in the developing human. Blood vessel and blood formation begins in the third week, and the heart is developmentally complete in the fifth week.
D	This is an inaccurate statement.

 

DIF:   Cognitive Level: Application        REF:  158

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Evaluation

 

6. A key finding from the Human Genome Project is:

a.	Approximately 30,000 to 40,000 genes make up the genome.
b.	All human beings are 80.99% identical at the DNA level.
c.	Human genes produce only one protein per gene; other mammals produce three proteins per gene.
d.	Single gene testing will become a standardized test for all pregnant patients in the future.

 

ANS: A

 

 

	Feedback
A	Approximately 30,000 to 40,000 genes make up the human genome; this is only twice as many as make up the genomes of roundworms and flies.
B	Human beings are 99.9% identical at the DNA level.
C	Most human genes produce at least three proteins.
D	Single gene testing (e.g., alpha-fetoprotein) is already standardized for prenatal care.

 

DIF:   Cognitive Level: Knowledge        REF:  140

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

 

7. You are a maternal-newborn nurse caring for a mother who just delivered a baby born with Down syndrome. What nursing diagnosis would be the most essential in caring for the mother of this infant?

a.	Disturbed body image
b.	Interrupted family processes
c.	Anxiety
d.	Risk for injury

 

ANS: B

 

	Feedback
A	Women commonly experience body image disturbances in the postpartum period, but this is unrelated to giving birth to a child with Down syndrome.
B	This mother likely will experience a disruption in the family process related to the birth of a baby with an inherited disorder.
C	The mother likely will have a mix of emotions that may include anxiety, guilt, and denial, but this is not the most essential nursing diagnosis for this family.
D	This nursing diagnosis is not applicable.

 

DIF:   Cognitive Level: Application        REF:  146

OBJ:  Client Needs: Psychosocial Integrity                                       TOP:   Nursing Process: Diagnosis

 

8. The nurse caring for the laboring woman should know that meconium is produced by:

a.	Fetal intestines.
b.	Fetal kidneys.
c.	Amniotic fluid.
d.	The placenta.

 

ANS: A

 

	Feedback
A	As the fetus nears term, fetal waste products accumulate in the intestines as dark green-to-black, tarry meconium.
B	Meconium is an accumulation of fetal waste products found in the intestines.
C	Meconium is an accumulation of fetal waste products found in the intestines.
D	Meconium is an accumulation of fetal waste products found in the intestines.

 

DIF:   Cognitive Level: Knowledge        REF:  160

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

 

9. In practical terms regarding genetic health care, nurses should be aware that:

a.	Genetic disorders affect equally people of all socioeconomic backgrounds, races, and ethnic groups.
b.	Genetic health care is more concerned with populations than individuals.
c.	The most important of all nursing functions is providing emotional support to the family during counseling.
d.	Taking genetic histories is the province of large universities and medical centers.

 

ANS: C

 

	Feedback
A	Although anyone may have a genetic disorder, certain disorders appear more often in certain ethnic and racial groups.
B	Genetic health care is highly individualized because treatments are based on the phenotypic responses of the individual.
C	Nurses should be prepared to help with a variety of stress reactions from a couple facing the possibility of a genetic disorder.
D	Individual nurses at any facility can take a genetic history, although larger facilities may have better support services.

 

DIF:   Cognitive Level: Comprehension  REF:  137

OBJ:  Client Needs: Psychosocial Integrity                                       TOP:   Nursing Process: Planning

 

10. With regard to prenatal genetic testing, nurses should be aware that:

a.	Maternal serum screening can determine whether a pregnant woman is at risk of carrying a fetus with Down syndrome.
b.	Carrier screening tests look for gene mutations of people already showing symptoms of a disease.
c.	Predisposition testing predicts with near certainty that symptoms will appear.
d.	Presymptomatic testing is used to predict the likelihood of breast cancer.

 

ANS: A

 

	Feedback
A	Maternal serum screening identifies the risk for the neural tube defect and the specific chromosome abnormality involved in Down syndrome.
B	Carriers of some diseases such as sickle cell disease do not display symptoms.
C	Predisposition testing determines susceptibility such as for breast cancer; presymptomatic testing indicates that, if the gene is present, symptoms are certain to appear.
D	Predisposition testing determines susceptibility such as for breast cancer; presymptomatic testing indicates that if the gene is present, symptoms are certain to appear.

 

DIF:   Cognitive Level: Knowledge        REF:  142

OBJ:  Client Needs: Physiologic Integrity                                         TOP:   Nursing Process: Planning

 

11. A woman who is 8 months pregnant asks the nurse, “Does my baby have any antibodies to fight infection?” The most appropriate response by the nurse is:

a.	“Your baby has all the immune globulins (Ig) necessary: IgG, IgM, and IgA.”
b.	“Your baby won’t receive any antibodies until he is born and you breastfeed him.”
c.	“Your baby does not have any antibodies to fight infection.”
d.	“Your baby has IgG and IgM.”

 

ANS: D

 

	Feedback
A	During the third trimester, the only Ig that crosses the placenta, IgG, provides passive acquired immunity to specific bacterial toxins. The fetus produces IgM by the end of the first trimester. IgAs are not produced by the baby.
B	By the third trimester, the fetus has IgG and IgM. Breastfeeding supplies the baby with IgA.
C	This is not an accurate statement. By the third trimester, the fetus has IgG and IgM.
D	During the third trimester, the only Ig that crosses the placenta, IgG, provides passive acquired immunity to specific bacterial toxins. The fetus produces IgM by the end of the first trimester.

 

DIF:   Cognitive Level: Application        REF:  162

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

12. Regarding the estimation and interpretation of the recurrence of risks for genetic disorders, nurses should be aware that:

a.	With a dominant disorder, the likelihood of the second child also having the condition is 100%.
b.	An autosomal recessive disease carries a one in eight risk of the second child also having the disorder.
c.	Disorders involving maternal ingestion of drugs carry a one in four chance of being repeated in the second child.
d.	The risk factor remains the same no matter how many affected children are already in the family.

 

ANS: D

 

	Feedback
A	In a dominant disorder, the likelihood of recurrence in subsequent children is 50% (one in two).
B	An autosomal recessive disease carries a one in four chance of recurrence.
C	Subsequent children would be at risk only if the mother continued to take drugs; the rate of risk would be difficult to calculate.
D	Each pregnancy is an independent event. The risk factor (e.g., one in two, one in four) remains the same for each child, no matter how many children are born to the family.

 

DIF:   Cognitive Level: Comprehension  REF:  140

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Diagnosis

 

13. The nurse must be cognizant that an individual’s genetic makeup is known as his or her:

a.	Genotype.
b.	Phenotype.
c.	Karyotype.
d.	Chromotype.

 

ANS: A

 

	Feedback
A	The genotype comprises all the genes the individual can pass on to a future generation.
B	The phenotype is the observable expression of an individual’s genotype.
C	The karyotype is a pictorial analysis of the number, form, and size of an individual’s chromosomes.
D	Genotype refers to an individual’s genetic makeup.

 

DIF:   Cognitive Level: Knowledge        REF:  144

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

 

14. A pregnant woman at 25 weeks of gestation tells the nurse that she dropped a pan last week and her baby jumped at the noise. Which response by the nurse is most accurate?

a.	“That must have been a coincidence; babies can’t respond like that.”
b.	“The fetus is demonstrating the aural reflex.”
c.	“Babies respond to sound starting at about 24 weeks of gestation.”
d.	“Let me know if it happens again; we need to report that to your midwife.”

ANS: C

 

	Feedback
A	This statement is inaccurate. Fetuses respond to sound by 24 weeks. Acoustic stimulations can evoke a fetal heart rate response.
B	There is no such thing as an aural reflex.
C	This statement is accurate.
D	This statement is not appropriate; it gives the impression that something is wrong.

 

DIF:   Cognitive Level: Application        REF:  160

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Evaluation

 

15. At approximately _____ weeks of gestation, lecithin is forming on the alveolar surfaces, the eyelids open, and the fetus measures approximately 27 cm crown to rump and weighs approximately 1110 g.

a.	20
b.	24
c.	28
d.	30

 

ANS: C

 

	Feedback
A	These milestones in human development occur at approximately 28 weeks.
B	These milestones in human development occur at approximately 28 weeks.
C	These are all milestones that occur at 28 weeks.
D	These milestones in human development occur at approximately 28 weeks.

 

DIF:   Cognitive Level: Knowledge        REF:  165

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

 

16. The _____ is/are responsible for oxygen and carbon dioxide transport to and from the maternal bloodstream.

a.	Decidua basalis
b.	Blastocyst
c.	Germ layer
d.	Chorionic villi

 

ANS: D

 

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

 

DIF:   Cognitive Level: Comprehension  REF:  153

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

 

17. Sally comes in for her first prenatal examination. This is her first child. She asks you (the nurse), “How does my baby get air inside my uterus?” The correct response is:

a.	“The baby’s lungs work in utero to exchange oxygen and carbon dioxide.”
b.	“The baby absorbs oxygen from your blood system.”
c.	“The placenta provides oxygen to the baby and excretes carbon dioxide into your bloodstream.”
d.	“The placenta delivers oxygen-rich blood through the umbilical artery to the baby’s abdomen.”

 

ANS: C

 

	Feedback
A	The fetal lungs do not function for respiratory gas exchange in utero.
B	The baby does not simply absorb oxygen from a woman’s blood system. Blood and gas transport occur through the placenta.
C	The placenta functions by supplying oxygen and excreting carbon dioxide to the maternal bloodstream.
D	The placenta delivers oxygen-rich blood through the umbilical vein and not the artery.

 

DIF:   Cognitive Level: Application        REF:  155

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

18. A maternity nurse should be aware of which fact about the amniotic fluid?

a.	It serves as a source of oral fluid and a repository for waste from the fetus.
b.	The volume remains about the same throughout the term of a healthy pregnancy.
c.	A volume of less than 300 ml is associated with gastrointestinal malformations.
d.	A volume of more than 2 L is associated with fetal renal abnormalities.

 

ANS: A

 

	Feedback
A	Amniotic fluid also cushions the fetus and helps maintain a constant body temperature.
B	The volume of amniotic fluid changes constantly.
C	Too little amniotic fluid (oligohydramnios) is associated with renal abnormalities.
D	Too much amniotic fluid (hydramnios) is associated with gastrointestinal and other abnormalities.

 

DIF:   Cognitive Level: Knowledge        REF:  154

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

 

19. Regarding the development of the respiratory system, maternity nurses should be aware that:

a.	The respiratory system does not begin developing until after the embryonic stage.
b.	The infant’s lungs are considered mature when the lecithin/sphingomyelin (L/S) ratio is 1:1, at about 32 weeks.
c.	Maternal hypertension can reduce maternal-placental blood flow, accelerating lung maturity.
d.	Fetal respiratory movements are not visible on ultrasound scans until at least 16 weeks.

 

ANS: C

 

	Feedback
A	Development of the respiratory system begins during the embryonic phase and continues into childhood.
B	The infant’s lungs are mature when the L/S ratio is 2:1, at about 35 weeks.
C	A reduction in placental blood flow stresses the fetus and increases blood levels of corticosteroids, thus accelerating lung maturity.
D	Lung movements have been seen on ultrasound scans at 11 weeks.

 

DIF:   Cognitive Level: Knowledge        REF:  158

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Diagnosis

 

20. Many parents-to-be have questions about multiple births. Maternity nurses should be able to tell them that:

a.	Twinning and other multiple births are increasing because of the use of fertility drugs and delayed childbearing.
b.	Dizygotic twins (two fertilized ova) have the potential to be conjoined twins.
c.	Identical twins are more common in Caucasian families.
d.	Fraternal twins are the same gender, usually male.

 

ANS: A

 

 

	Feedback
A	If the parents-to-be are older and have taken fertility drugs, they would be very interested in this information.
B	Conjoined twins are monozygotic; they are from a single fertilized ovum in which division occurred very late.
C	Identical twins show no racial or ethnic preference; fraternal twins are more common among African-American women.
D	Fraternal twins can be different genders or the same gender. Identical twins are the same gender.

 

DIF:   Cognitive Level: Knowledge        REF:  162

OBJ:  Client Needs: Health Promotion and Maintenance: Family Planning

TOP:  Nursing Process: Planning

 

21. The nurse caring for a pregnant patient knows that her health teaching regarding fetal circulation has been effective when the patient reports that she has been sleeping:

a.	In a side-lying position.
b.	On her back with a pillow under her knees.
c.	With the head of the bed elevated.
d.	On her abdomen.

 

ANS: A

 

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

 

DIF:   Cognitive Level: Analysis             REF:  157

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Evaluation

 

MULTIPLE RESPONSE

 

1. Congenital disorders refer to conditions that are present at birth. These disorders may be inherited and caused by environmental factors or maternal malnutrition. Toxic exposures have the greatest effect on development between 15 and 60 days of gestation. For the nurse to be able to conduct a complete assessment of the newly pregnant patient, she should understand the significance of exposure to known human teratogens. These include (choose all that apply):

a.	Infections.
b.	Radiation.
c.	Maternal conditions.
d.	Drugs.
e.	Chemicals.

 

ANS: A, B, C, D, E

 

	Feedback
Correct	Exposure to radiation and a number of infections may result in profound congenital deformities. These include but are not limited to varicella, rubella, syphilis, parvovirus, cytomegalovirus, and toxoplasmosis. Certain maternal conditions such as diabetes and phenylketonuria may also affect organs and other parts of the embryo during this developmental period. Drugs such as antiseizure medication and some antibiotics, as well as chemicals, including lead, mercury, tobacco, and alcohol, also may result in structural and functional abnormalities.
Incorrect	None

 

DIF:   Cognitive Level: Comprehension  REF:  148

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

 

COMPLETION

 

1. ____________________ twins is another term for fraternal twins. These twins may be the same or different sexes and genetically are no more alike than siblings born at different times.

 

ANS:

Dizygotic

 

Identical or monozygotic twins develop from one fertilized ovum, which then divides. They are the same sex and the same genotype. When two mature ova are produced in one ovarian cycle, both have the potential to be fertilized by separate sperm. This results in two zygotes, or dizygotic twins.

 

DIF:   Cognitive Level: Comprehension  REF:  162

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Diagnosis

 

2. Very fine hairs, called ____________________, appear first at 12 weeks of gestation on the fetus’s eyebrows and upper lip. By 20 weeks they cover the entire body.

 

ANS:

Lanugo

 

By 28 weeks the scalp hair is longer than these fine hairs, which thin and may disappear by term gestation.

 

DIF:   Cognitive Level: Comprehension  REF:  162

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

 

TRUE/FALSE

 

1. The fetal concentration of glucose is lower than the glucose level in the maternal blood because of the rapid metabolism by the fetus.

 

ANS: T

This fetal requirement demands larger concentrations of glucose than simple diffusion can provide. Therefore maternal glucose moves into the fetal circulation by active transport.

 

DIF:   Cognitive Level: Comprehension  REF:  161

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

 

 

 

Lowdermilk: Maternity Nursing, 8th Edition

 

Chapter 16: Physiologic and Behavioral Adaptations of the Newborn

 

Test Bank

 

MULTIPLE CHOICE

 

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:

a.	Transition period.
b.	First period of reactivity.
c.	Organizational stage.
d.	Second period of reactivity.

 

ANS: B

 

	Feedback
A	The transition period is the phase between intrauterine and extrauterine existence.
B	The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase.
C	There is no such phase.
D	The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.

 

DIF:   Cognitive Level: Comprehension  REF:  439

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

2. Part of the health assessment of a newborn is observing the infant’s breathing pattern. A full-term newborn’s breathing pattern is predominantly:

a.	Abdominal with synchronous chest movements.
b.	Chest breathing with nasal flaring.
c.	Diaphragmatic with chest retraction.
d.	Deep with a regular rhythm.

 

ANS: A

 

	Feedback
A	In normal infant respiration, the chest and abdomen rise synchronously, and breaths are shallow and irregular.
B	Breathing with nasal flaring is a sign of respiratory distress.
C	Diaphragmatic breathing with chest retraction is a sign of respiratory distress.
D	Infant breaths are shallow and irregular.

 

DIF:   Cognitive Level: Comprehension  REF:  439

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

 

3. While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is:

a.	80 to 100 beats/min.
b.	100 to 120 beats/min.
c.	120 to 140 beats/min.
d.	150 to 180 beats/min.

 

ANS: C

 

	Feedback
A	The newborn’s heart rate may be about 85 to 100 beats/min while sleeping.
B	The infant’s heart rate typically is a bit higher when alert but quiet.
C	The average infant heart rate while awake is 120 to 140 beats/min.
D	A heart rate of 150 to 180 beats/min is typical when the infant cries.

 

DIF:   Cognitive Level: Comprehension  REF:  441

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

 

4. A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant’s body temperature every hour. Maintaining the newborn’s body temperature is important for preventing:

a.	Respiratory depression.
b.	Cold stress.
c.	Tachycardia.
d.	Vasoconstriction.

 

ANS: B

 

	Feedback
A	The primary reason for placing a newborn under a radiant heat warmer is to prevent heat loss and cold stress. Cold stress results in an increased respiratory rate and vasoconstriction.
B	Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects of cold stress.
C	The primary reason for placing a newborn under a radiant heat warmer is to prevent heat loss and cold stress. Cold stress results in an increased respiratory rate and vasoconstriction.
D	The primary reason for placing a newborn under a radiant heat warmer is to prevent heat loss and cold stress. Cold stress results in an increased respiratory rate and vasoconstriction.

 

DIF:   Cognitive Level: Comprehension  REF:  443

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

 

5. An African-American woman noticed some bruises on her newborn girl’s buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called:

a.	Lanugo.
b.	Vascular nevi.
c.	Nevus flammeus.
d.	Mongolian spots.

 

ANS: D

 

	Feedback
A	Lanugo is the fine, downy hair seen on a term newborn.
B	A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma.
C	A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face.
D	A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African.

 

DIF:   Cognitive Level: Comprehension  REF:  449

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Diagnosis

 

6. 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.
b.	Erythema neonatorum.
c.	Harlequin color.
d.	Vernix caseosa.

 

ANS: A

 

	Feedback
A	Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days.
B	Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites.
C	The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation.
D	Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.

 

DIF:   Cognitive Level: Knowledge        REF:  447

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Diagnosis

 

7. The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is:

a.	Closure of fetal shunts in the circulatory system.
b.	Full function of the immune defense system at birth.
c.	Maintenance of a stable temperature.
d.	Initiation and maintenance of respirations.

 

ANS: D

 

	Feedback
A	The cardiovascular system changes markedly after birth as a result of fetal respiration, which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system.
B	The infant relies on passive immunity received from the mother for the first 3 months of life.
C	After the establishment of respirations, heat regulation is critical to newborn survival.
D	The most critical adjustment of a newborn at birth is the establishment of respirations.

 

DIF:   Cognitive Level: Comprehension  REF:  439

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

 

8. 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:

a.	“Infants can see very little until about 3 months of age.”
b.	“Infants can track their parent’s eyes and distinguish patterns; they prefer complex patterns.”
c.	“The infant’s eyes must be protected. Infants enjoy looking at brightly colored stripes.”
d.	“It’s important to shield the newborn’s eyes. Overhead lights help them see better.”

 

ANS: B

	Feedback
A	Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm.
B	This is an accurate statement.
C	Infants prefer to look at complex patterns, regardless of the color.
D	Infants prefer low illumination and withdraw from bright light.

 

DIF:   Cognitive Level: Application        REF:  475

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

9. 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:

a.	Tonic neck reflex.
b.	Glabellar (Myerson) reflex.
c.	Babinski reflex.
d.	Moro reflex.

 

ANS: D

 

	Feedback
A	The tonic neck reflex occurs when the infant extends the leg on the side to which the infant’s head simultaneously turns.
B	The glabellar reflex is elicited by tapping on the infant’s head while the eyes are open. A characteristic response is blinking for the first few taps.
C	The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.
D	The characteristics displayed by the infant are associated with a positive Moro reflex.

 

DIF:   Cognitive Level: Comprehension  REF:  454

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

 

10. 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:

a.	Notify the physician immediately.
b.	Move the newborn to an isolation nursery.
c.	Document the finding as erythema toxicum.
d.	Take the newborn’s temperature and obtain a culture of one of the vesicles.

 

ANS: C

 

	Feedback
A	This is a normal finding that does not require notification of the physician.
B	This is a normal finding that does not require the newborn to be isolated.
C	Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites.
D	This is a normal finding that does not require any additional interventions.

 

DIF:   Cognitive Level: Application        REF:  450

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

 

11. 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.”
b.	“That’s transitional stool.”
c.	“That means your baby is bleeding internally.”
d.	“Oh, don’t worry about that. It’s okay.”

 

ANS: A

 

	Feedback
A	This is an accurate statement and the most appropriate response.
B	Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding.
C	This statement is not accurate.
D	This statement is not appropriate. It is belittling to the father and does not educate him about the normal stool patterns of his daughter.

 

DIF:   Cognitive Level: Application        REF:  446

OBJ:  Client Needs: Health Promotion and Maintenance

TOP:  Nursing Process: Implementation

 

12. The transition period between intrauterine and extrauterine existence for the newborn:

a.	Consists of four phases, two reactive and two of decreased responses.
b.	Lasts from birth to day 28 of life.
c.	Applies to full-term births only.
d.	Varies by socioeconomic status and the mother’s age.

 

ANS: B

 

	Feedback
A	The transition period has three phases: first reactivity, decreased response, and second reactivity.
B	Changes begin right after birth; the cutoff time at which the transition is considered to be over (although the baby keeps changing) is 28 days.
C	All newborns experience this transition regardless of age or type of birth.
D	Although stress can cause variation in the phases, the mother’s age and wealth do not disturb the pattern.

 

DIF:   Cognitive Level: Comprehension  REF:  439

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Evaluation

 

13. With regard to the newborn’s developing cardiovascular system, nurses should be aware that:

a.	The heart rate of a crying infant may rise to 120 beats/min.
b.	Heart murmurs heard after the first few hours are cause for concern.
c.	The point of maximal impulse (PMI) often is visible on the chest wall.
d.	Persistent bradycardia may indicate respiratory distress syndrome (RDS).

 

ANS: C

 

	Feedback
A	The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min.
B	Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further.
C	The newborn’s thin chest wall often allows the PMI to be seen.
D	Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

 

DIF:   Cognitive Level: Comprehension  REF:  441

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

 

14. By knowing about variations in infants’ blood count, nurses can explain to their patients that:

a.	A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord.
b.	The early high white blood cell (WBC) count is normal at birth and should decrease rapidly.
c.	Platelet counts are higher than in adults for a few months.
d.	Even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly.

 

ANS: B

 

	Feedback
A	Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count.
B	The WBC count is high the first day of birth and then declines rapidly.
C	The platelet count essentially is the same for newborns and adults.
D	Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant.

 

DIF:   Cognitive Level: Comprehension  REF:  442

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

15. What infant response to cool environmental conditions is either NOT effective or NOT available to them?

a.	Constriction of peripheral blood vessels
b.	Metabolism of brown fat
c.	Increased respiratory rates
d.	Unflexing from the normal position

 

ANS: D

 

	Feedback
A	The newborn’s body is able to constrict the peripheral blood vessels to reduce heat loss.
B	Burning brown fat generates heat.
C	The respiratory rate may rise to stimulate muscular activity, which generates heat.
D	The newborn’s flexed position guards against heat loss because it reduces the amount of body surface exposed to the environment.

 

DIF:   Cognitive Level: Comprehension  REF:  443

OBJ:  Client Needs: Physiologic Integrity                                         TOP:   Nursing Process: Planning

 

16. With regard to the functioning of the renal system in newborns, nurses should be aware that:

a.	The pediatrician should be notified if the newborn has not voided in 24 hours.
b.	Breastfed infants likely will void more often during the first days after birth.
c.	“Brick dust” or blood on a diaper is always cause to notify the physician.
d.	Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.

 

ANS: A

 

	Feedback
A	A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician.
B	Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants void less during this time because the mother’s breast milk has not come in yet.
C	Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if there is no apparent cause of bleeding.
D	Weight loss from fluid loss might take 14 days to regain.

 

DIF:   Cognitive Level: Comprehension  REF:  469

OBJ:  Client Needs: Physiologic Integrity

TOP:  Nursing Process: Planning, Implementation

 

17. With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that:

a.	The newborn’s cheeks are full because of normal fluid retention.
b.	The nipple of the bottle or breast must be placed well inside the baby’s mouth because teeth have been developing in utero, and one or more may even be through.
c.	Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby’s head.
d.	Bacteria are already present in the infant’s GI tract at birth, because they traveled through the placenta.

 

ANS: C

 

	Feedback
A	The newborn’s cheeks are full because of well-developed sucking pads.
B	Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx.
C	Avoiding overfeeding can also reduce regurgitation.
D	Bacteria are not present at birth, but they soon enter through various orifices.

 

DIF:   Cognitive Level: Comprehension  REF:  445

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

18. The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called:

a.	Vernix caseosa.
b.	Surfactant.
c.	Caput succedaneum.
d.	Acrocyanosis.

 

ANS: A

 

	Feedback
A	This protection is needed because the infant’s skin is so thin.
B	Surfactant is a protein that lines the alveoli of the infant’s lungs.
C	Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head.
D	Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

 

DIF:   Cognitive Level: Knowledge        REF:  447

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

 

19. An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver would then:

a.	Tell the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking.
b.	Alert the physician that the infant has a dislocated hip.
c.	Inform the parents and physician that molding has not taken place.
d.	Suggest that, if the condition does not change, surgery to correct vision problems might be needed.

 

ANS: B

 

	Feedback
A	The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.
B	The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.
C	The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.
D	The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.

 

DIF:   Cognitive Level: Application        REF:  451

OBJ:  Client Needs: Health Promotion and Maintenance

TOP:  Nursing Process: Implementation

 

20. One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the:

a.	Incompletely developed neuromuscular system.
b.	Primitive reflex system.
c.	Presence of various sleep-wake states.
d.	Cerebellum growth spurt.

 

ANS: D

 

	Feedback
A	The neuromuscular system is almost completely developed at birth. The vulnerability of the brain likely is the result of the cerebellum growth spurt.
B	The reflex system is not relevant. The vulnerability of the brain likely is the result of the cerebellum growth spurt.
C	The various sleep-wake states are not relevant. The vulnerability of the brain is likely the result of the cerebellum growth spurt.
D	The vulnerability of the brain is likely the result of the cerebellum growth spurt.

 

DIF:   Cognitive Level: Analysis             REF:  457

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Diagnosis

 

21. The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is:

a.	Vision.
b.	Hearing.
c.	Smell.
d.	Taste.

 

ANS: A

 

	Feedback
A	The visual system continues to develop for the first 6 months.
B	As soon as the amniotic fluid drains from the ear (minutes), the infant’s hearing is similar to that of an adult.
C	Newborns have a highly developed sense of smell.
D	The newborn can distinguish and react to various tastes.

 

DIF:   Cognitive Level: Knowledge        REF:  475

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

22. 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.
b.	Only happens as the result of a forceps or vacuum delivery.
c.	Is present immediately after birth.
d.	Will gradually absorb over the first few months of life.

 

ANS: A

 

	Feedback
A	Bleeding may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. The soft, irreducible fullness does not pulsate or bulge when the infant cries.
B	Low forceps and other difficult extractions may result in bleeding. However, these can also occur spontaneously.
C	The swelling may appear unilaterally or bilaterally and is usually minimal or absent at birth. It increases over the first 2 to 3 days of life.
D	Cephalhematomas disappear gradually over 2 to 3 weeks. A less common condition results in calcification of the hematoma, which may persist for months.

 

DIF:   Cognitive Level: Knowledge        REF:  448

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

MULTIPLE RESPONSE

 

1. What are modes of heat loss in the newborn? Choose all that apply.

a.	Perspiration
b.	Convection
c.	Radiation
d.	Conduction
e.	Urination

 

ANS: B, C, D

 

	Feedback
Correct	Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn.
Incorrect	These are not modes of heat loss in newborns.

 

DIF:   Cognitive Level: Analysis             REF:  443

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Diagnosis

 

TRUE/FALSE

 

1. One reason hyperthermia develops more rapidly in the newborn than in the adult is that sweat glands have not formed yet.

 

ANS: F

Newborns have six times as many sweat glands per unit area as adults; however, they do not yet function.

 

DIF:   Cognitive Level: Knowledge        REF:  444

OBJ:  Client Needs: Physiologic Integrity

TOP:  Nursing Process: Assessment, Diagnosis