Module 33 Reproduction: Nursing: A Concept-Based Approach To Learning, 2e (Pearson)

Nursing: A Concept-Based Approach to Learning, 2e (Pearson)
Module 33 Reproduction
The Concept of Reproduction
1) A client at 8 weeks' gestation has been advised to have the embryo undergo genetic testing.
The nurse instructs the client that the area of the embryo being tested is which of the following?
A) Chorion
B) Amnion
C) Ectoderm
D) Endometrium
Answer: A
Explanation: A) The chorion is the outermost embryonic membrane and develops into chorionic
villi, which can be used for early genetic testing of the embryo at 8 to 11 weeks' gestation by
chorionic villi sampling. The endometrium is the lining of the uterus and will not be used for
genetic testing of the embryo. The ectoderm is a germ layer and will develop into specific
structures within the developing fetus. The amnion will develop into amniotic fluid, which can
also be sampled for genetic testing but may not be developed by 8 weeks' gestation.
B) The chorion is the outermost embryonic membrane and develops into chorionic villi, which
can be used for early genetic testing of the embryo at 8 to 11 weeks' gestation by chorionic villi
sampling. The endometrium is the lining of the uterus and will not be used for genetic testing of
the embryo. The ectoderm is a germ layer and will develop into specific structures within the
developing fetus. The amnion will develop into amniotic fluid, which can also be sampled for
genetic testing but may not be developed by 8 weeks' gestation.
C) The chorion is the outermost embryonic membrane and develops into chorionic villi, which
D) The chorion is the outermost embryonic membrane and develops into chorionic villi, which
Page Ref: 2022
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 1. Summarize the structure and physiology of the reproductive system
related to childbearing.
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2) A client informs the nurse of a positive result from an early pregnancy test but wants to be
sure that she is pregnant. Which response is the most appropriate for the nurse to make?
A) "Pregnancy can be detected 24 to 48 hours after conception, depending on the test."
B) "Pregnancy cannot be detected before 12 days after conception."
C) "Most early pregnancy tests are not reliable."
D) "Most pregnancy tests cannot differentiate between pregnancy and premenstrual hormone
levels."
Answer: A
Explanation: A) Early pregnancy factor, an immunosuppressant protein, is secreted by the
trophoblastic cells of the developing embryo. This factor appears in the maternal serum within
24 to 48 hours after fertilization and forms the basis of a pregnancy test during the first 10 days
of development. The nurse should respond that pregnancy can be detected 24 to 48 hours after
conception, depending upon the test. It is not true that most early pregnancy tests are not reliable.
Pregnancy can be detected before 12 days after conception. Early pregnancy tests assess for the
presence of trophoblastic cells and not premenstrual hormone levels.
B) Early pregnancy factor, an immunosuppressant protein, is secreted by the trophoblastic cells
of the developing embryo. This factor appears in the maternal serum within 24 to 48 hours after
fertilization and forms the basis of a pregnancy test during the first 10 days of development. The
nurse should respond that pregnancy can be detected 24 to 48 hours after conception, depending
upon the test. It is not true that most early pregnancy tests are not reliable. Pregnancy can be
detected before 12 days after conception. Early pregnancy tests assess for the presence of
trophoblastic cells and not premenstrual hormone levels.
C) Early pregnancy factor, an immunosuppressant protein, is secreted by the trophoblastic cells
D) Early pregnancy factor, an immunosuppressant protein, is secreted by the trophoblastic cells
Page Ref: 2021
Learning Outcome: 5. Describe diagnostic and laboratory tests used to determine the individual's
reproductive status.
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3) The nurse is instructing a client who is at 10 weeks' gestation on smoking cessation and
avoiding substance abuse because these substances will:
A) Interfere with hormone excretion of the fetus.
B) Facilitate the transfer of viruses and other diseases into the developing fetus.
C) Pass into the developing fetus through the placenta very easily.
D) Stop the synthesis of protein in the developing fetus.
Answer: C
Explanation: A) Byproducts of smoking and substance use pass from the mother to the fetus
through the placenta via simple diffusion. These substances have adverse effects on the
developing fetus. Smoking byproducts and abused substances do not interfere with hormone
excretion of the fetus or stop the synthesis of protein in the fetus. They do not facilitate the
transfer of viruses and other diseases into the developing fetus.
B) Byproducts of smoking and substance use pass from the mother to the fetus through the
placenta via simple diffusion. These substances have adverse effects on the developing fetus.
Smoking byproducts and abused substances do not interfere with hormone excretion of the fetus
or stop the synthesis of protein in the fetus. They do not facilitate the transfer of viruses and
other diseases into the developing fetus.
C) Byproducts of smoking and substance use pass from the mother to the fetus through the
D) Byproducts of smoking and substance use pass from the mother to the fetus through the
Page Ref: 2026
Cognitive Level: Analyzing
Learning Outcome: 6. Explain management of reproductive health and prevention of
reproductive illness.
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4) A client at 12 weeks' gestation with her first child tells the nurse that she is concerned that her
husband does not want the baby because he has a renewed interest in playing tennis and visiting
with college friends after work. The nurse realizes the client is describing a(n):
A) Father's reaction normally seen in the second trimester of pregnancy.
B) Father's reaction normally seen in the third trimester of pregnancy.
C) Father's reaction normally seen in the first trimester of pregnancy.
D) Atypical reaction of the father to pregnancy that should be further examined.
Answer: C
Explanation: A) Pregnancy produces psychological changes in the mother and father of the
child. A reaction seen in the father during the first trimester of pregnancy is a renewed interest in
hobbies or activities outside of the family and is usually a sign of stress. This behavior is not
seen in the second or third trimesters and is not an atypical reaction that should be further
examined.
B) Pregnancy produces psychological changes in the mother and father of the child. A reaction
seen in the father during the first trimester of pregnancy is a renewed interest in hobbies or
activities outside of the family and is usually a sign of stress. This behavior is not seen in the
second or third trimesters and is not an atypical reaction that should be further examined.
C) Pregnancy produces psychological changes in the mother and father of the child. A reaction
D) Pregnancy produces psychological changes in the mother and father of the child. A reaction
Page Ref: 2039
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Learning Outcome: 2. Examine the relationship between reproduction and other
concepts/systems.
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5) After learning that she is pregnant, an adolescent client asks for information that she needs to
know about the pregnancy and the baby because she cannot afford to see a doctor. The nurse
should do which of the following?
A) Provide the client with information on resources to assist with medical care during the
pregnancy and after delivery.
B) Instruct the client on aspects of pregnancy, fetal development, and labor and delivery.
C) Ask the client if her parents are aware that she is pregnant and if she is covered by their
medical insurance.
D) Tell the client that the father of the baby is responsible to pay for medical care for her during
the pregnancy and after delivery.
Answer: A
Explanation: A) Poverty and low education levels are associated with adolescent pregnancy. The
nurse should support the client by providing information on resources to assist with medical care
during the pregnancy and after delivery. The nurse should not instruct the client on all aspects of
the pregnancy, including fetal development, labor, and delivery, as this can be overwhelming to
the client. The nurse should not ask the client if the parents are aware of the pregnancy nor tell
the client that the baby's father is responsible for her medical care; these actions do not address
the client's needs.
B) Poverty and low education levels are associated with adolescent pregnancy. The nurse should
support the client by providing information on resources to assist with medical care during the
pregnancy and after delivery. The nurse should not instruct the client on all aspects of the
pregnancy, including fetal development, labor, and delivery, as this can be overwhelming to the
client. The nurse should not ask the client if the parents are aware of the pregnancy nor tell the
client that the baby's father is responsible for her medical care; these actions do not address the
client's needs.
C) Poverty and low education levels are associated with adolescent pregnancy. The nurse should
client's needs.
D) Poverty and low education levels are associated with adolescent pregnancy. The nurse should
client's needs.
Page Ref: 2041, 2043
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent care
across the life span for pregnant individuals and their families.
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6) An adolescent client at 34 weeks' gestation tells the nurse that she cannot wait for "all of this
to be over" so she can resume her normal life. With which question should the nurse respond to
this client?
A) "Are your friends excited about the baby coming and planning a shower for you?"
B) "Have you done anything to prepare for the baby coming home after delivery?"
C) "Do you miss school and spending time with your friends?"
D) "Have you been able to get enough rest while keeping up with your studies?"
Answer: B
Explanation: A) Developmental tasks of the third trimester include preparing for the baby with
clothing and supplies. The nurse needs to assess what the client has done to prepare for the baby
coming home after delivery. The nurse should not focus on the client missing school and friends
because these are not developmental tasks associated with the pregnancy.
B) Developmental tasks of the third trimester include preparing for the baby with clothing and
supplies. The nurse needs to assess what the client has done to prepare for the baby coming home
after delivery. The nurse should not focus on the client missing school and friends because these
are not developmental tasks associated with the pregnancy.
C) Developmental tasks of the third trimester include preparing for the baby with clothing and
D) Developmental tasks of the third trimester include preparing for the baby with clothing and
Page Ref: 2037-2038
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent care
across the life span for pregnant individuals and their families.
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7) A client who says she is "about 6 weeks pregnant" hears the baby's heartbeat for the first time
through a Doppler. What does this assessment finding indicate to the nurse?
A) The mother is at 8 to 12 weeks' gestation.
B) The mother is at 16 weeks' gestation.
C) The mother is at 4 to 8 weeks' gestation.
D) The mother is at 20 weeks' gestation.
Answer: A
Explanation: A) The ultrasonic Doppler device is the primary tool for assessing fetal heartbeat.
It can detect fetal heartbeat, on average, at 8 to 12 weeks' gestation. If an ultrasonic Doppler is
not available, a fetoscope may be used. The fetal heartbeat can be detected by fetoscope as early
as week 16 and almost always by 19 or 20 weeks' gestation. The mother is not at 4 to 8 weeks'
gestation because the Doppler device detected fetal heartbeat. If the mother has not yet heard the
fetal heartbeat, she must be at less than 16 or 20 weeks' gestation.
B) The ultrasonic Doppler device is the primary tool for assessing fetal heartbeat. It can detect
fetal heartbeat, on average, at 8 to 12 weeks' gestation. If an ultrasonic Doppler is not available, a
fetoscope may be used. The fetal heartbeat can be detected by fetoscope as early as week 16 and
almost always by 19 or 20 weeks' gestation. The mother is not at 4 to 8 weeks' gestation because
the Doppler device detected fetal heartbeat. If the mother has not yet heard the fetal heartbeat,
she must be at less than 16 or 20 weeks' gestation.
C) The ultrasonic Doppler device is the primary tool for assessing fetal heartbeat. It can detect
D) The ultrasonic Doppler device is the primary tool for assessing fetal heartbeat. It can detect
Page Ref: 2035
Learning Outcome: 4. Differentiate common physical assessment procedures used to examine
reproductive health across the life span.
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8) A client is surprised to learn of being pregnant because the home pregnancy test was negative
when it was used a month ago. What should the nurse respond to this client?
A) "Home pregnancy tests are unreliable and should not be used without an ultrasound afterward
to confirm pregnancy."
B) "Home pregnancy tests can provide a false negative and should be repeated in a week if your
period has not yet started."
C) "Home pregnancy tests are unreliable and should not be used without a blood sample being
drawn afterward."
D) "Home pregnancy tests lose their effectiveness after 6 months, and your kit was probably
old."
Answer: B
Explanation: A) False-negative results with home pregnancy tests are high, and so follow up is
indicated if symptoms of pregnancy occur. If the results are negative, the woman should repeat
the test in 1 week if she has not started her period. Home pregnancy tests do not lose their
effectiveness for 2 years. Blood sampling and ultrasounds are not required to confirm the results
of home pregnancy tests.
B) False-negative results with home pregnancy tests are high, and so follow up is indicated if
symptoms of pregnancy occur. If the results are negative, the woman should repeat the test in 1
week if she has not started her period. Home pregnancy tests do not lose their effectiveness for 2
years. Blood sampling and ultrasounds are not required to confirm the results of home pregnancy
tests.
C) False-negative results with home pregnancy tests are high, and so follow up is indicated if
tests.
D) False-negative results with home pregnancy tests are high, and so follow up is indicated if
tests.
Page Ref: 2035
Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's
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9) The nurse notes that a client who is 18 weeks pregnant is experiencing gum hyperplasia with
areas of inflammation. What actions should the nurse take regarding this finding?
Select all that apply.
A) Encourage the use of dental floss to reduce gum overgrowth.
B) Do nothing because this is a normal finding with pregnancy.
C) Suggest seeing a dentist.
D) Discuss current dental habits.
E) Recommend flushing the mouth with hydrogen peroxide daily.
Answer: C, D
Explanation: A) Hyperplasia of the gums can occur during pregnancy because of estrogen.
However the client does have areas of inflammation. The nurse should discuss the client's current
dental habits and suggest the client see a dentist. Doing nothing will not address the areas of
inflammation. Flushing with hydrogen peroxide is not recommended for gum inflammation.
Dental floss will not prevent gum hyperplasia.
B) Hyperplasia of the gums can occur during pregnancy because of estrogen. However the client
does have areas of inflammation. The nurse should discuss the client's current dental habits and
suggest the client see a dentist. Doing nothing will not address the areas of inflammation.
Flushing with hydrogen peroxide is not recommended for gum inflammation. Dental floss will
not prevent gum hyperplasia.
C) Hyperplasia of the gums can occur during pregnancy because of estrogen. However the client
D) Hyperplasia of the gums can occur during pregnancy because of estrogen. However the client
E) Hyperplasia of the gums can occur during pregnancy because of estrogen. However the client
Page Ref: 2031
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in reproduction.
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10) A client in the first trimester of pregnancy complains of a vaginal discharge and is concerned
that the baby is infected. The nurse should instruct the client to do which of the following?
A) Avoid douching.
B) Keep the vaginal area clean and wear cotton underwear.
C) See the primary care physician to assess for a vaginal infection.
D) Limit bathing to 2 times a week.
E) Limit dairy products and use lactose-free products whenever possible.
Answer: A, B
Explanation: A) One client discomfort seen in the first trimester of pregnancy is increased
vaginal secretions. The nurse should instruct the client to keep the vaginal area clean and wear
cotton underwear. The nurse should also instruct the client to avoid douching. The nurse should
not instruct the client to limit bathing or dairy products; those actions will not decrease vaginal
secretions and may offer other risks. The nurse should not suggest that the client has an infection
because increased secretions are expected during the first trimester.
B) One client discomfort seen in the first trimester of pregnancy is increased vaginal secretions.
The nurse should instruct the client to keep the vaginal area clean and wear cotton underwear.
The nurse should also instruct the client to avoid douching. The nurse should not instruct the
client to limit bathing or dairy products; those actions will not decrease vaginal secretions and
may offer other risks. The nurse should not suggest that the client has an infection because
increased secretions are expected during the first trimester.
C) One client discomfort seen in the first trimester of pregnancy is increased vaginal secretions.
D) One client discomfort seen in the first trimester of pregnancy is increased vaginal secretions.
E) One client discomfort seen in the first trimester of pregnancy is increased vaginal secretions.
Page Ref: 2030
Learning Outcome: 3. Identify commonly occurring alterations in reproduction and their related
therapies.
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11) A client who is in the first trimester of pregnancy tells the nurse that she is constantly
nauseated and can vomit at any time. To assist this client, the nurse should instruct her to do
which of the following?
A) Drink a glass of water every time nausea occurs.
B) Take a multivitamin without iron each day.
C) Take over-the-counter Benadryl for the nausea.
D) Take a multivitamin with iron each day.
Answer: B
Explanation: A) Multivitamins without iron will reduce the nausea associated with the first
trimester of pregnancy. The nurse should not suggest taking the vitamin with iron, which can
contribute to nausea. The nurse should not instruct the client to drink a glass of water every time
nausea occurs because this could lead to the ingestion of high quantities of water. The nurse
should also not instruct the client to ingest an over-the-counter medication without discussing
this with her physician.
B) Multivitamins without iron will reduce the nausea associated with the first trimester of
pregnancy. The nurse should not suggest taking the vitamin with iron, which can contribute to
nausea. The nurse should not instruct the client to drink a glass of water every time nausea
occurs because this could lead to the ingestion of high quantities of water. The nurse should also
not instruct the client to ingest an over-the-counter medication without discussing this with her
physician.
C) Multivitamins without iron will reduce the nausea associated with the first trimester of
physician.
D) Multivitamins without iron will reduce the nausea associated with the first trimester of
physician.
Page Ref: 2031
Client Need: Physiological Integrity
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in reproduction.
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12) A nurse working in an OB/GYN outpatient clinic finds that on a routine anemia screen a
pregnant client in her second trimester has a hemoglobin of 10 g/dL and a serum ferritin level of
11 mg/L. The woman states that she has felt tired a lot, but otherwise feels fine. What actions
would be expected in caring for this client?
A) Complete a further history and exam to carefully assess for any potential cause of bleeding.
B) Review a list of iron-rich foods and explore with the client how she can increase dietary iron.
C) Have the client continue her usual daily prenatal vitamin dose.
D) Stress the importance of complying with an increase in iron supplementation to 100 mg per
day.
E) Ask the client to return in 2 months for a repeat check of her serum iron levels.
F) Order a screening for sickle cell anemia.
Answer: A, B, C, D
Explanation: A) Iron deficiency anemia is the most common medical complication of
pregnancy; thus, low hemoglobin and ferritin levels during pregnancy suggest an inadequate
intake of dietary iron as the probable cause of her anemia. Although the client otherwise reports
feeling well, the nurse should review her history and physical findings for any other possible
causes of decreased hemoglobin levels (e.g., tendency to bruise easily, uterine bleeding, dark
stools) to help ensure that another cause is not missed. Given that the client's anemia is likely
from iron deficiency, the nurse needs to emphasize the importance of eating iron-rich foods and
complying with the increased iron supplementation (from the 27 mg/day typical in prenatal
vitamins to between 60 and 120 mg/day) rather than continuing with her usual daily prenatal
vitamin dose. A screening for sickle cell anemia is not indicated given the information presented.
The client should return in 1 month for a re-check of her hemoglobin levels; if improvement is
not seen, then further evaluation is indicated.
B) Iron deficiency anemia is the most common medical complication of pregnancy; thus, low
hemoglobin and ferritin levels during pregnancy suggest an inadequate intake of dietary iron as
the probable cause of her anemia. Although the client otherwise reports feeling well, the nurse
should review her history and physical findings for any other possible causes of decreased
hemoglobin levels (e.g., tendency to bruise easily, uterine bleeding, dark stools) to help ensure
that another cause is not missed. Given that the client's anemia is likely from iron deficiency, the
nurse needs to emphasize the importance of eating iron-rich foods and complying with the
increased iron supplementation (from the 27 mg/day typical in prenatal vitamins to between 60
and 120 mg/day) rather than continuing with her usual daily prenatal vitamin dose. A screening
for sickle cell anemia is not indicated given the information presented. The client should return
in 1 month for a re-check of her hemoglobin levels; if improvement is not seen, then further
evaluation is indicated.
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C) Iron deficiency anemia is the most common medical complication of pregnancy; thus, low
D) Iron deficiency anemia is the most common medical complication of pregnancy; thus, low
E) Iron deficiency anemia is the most common medical complication of pregnancy; thus, low
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F) Iron deficiency anemia is the most common medical complication of pregnancy; thus, low
Page Ref: 2031
Learning Outcome: 6. Explain management of reproductive health and prevention of
reproductive illness.
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13) What is the test or measurement that provides an early indicator of fetal lung maturity in
high-risk pregnancies?
A) Serum or urine human chorionic gonadotropin (hCG)
B) Fetal heartbeat by Doppler
C) Fetal heartbeat by fetoscope
D) Fetal movement
Answer: A
Explanation: A) The earliest indicator of fetal viability is the beta subunit of human hCG
measured in maternal blood or urine. hCG normally rises at 10-12 weeks of gestation, and this
initial elevation is important in monitoring high-risk pregnancies where viability has not been
documented. A lack of increasing hCG levels, abnormally high levels of hCG, or an accelerated
rise of hCG suggest the need for further investigation of the pregnancy and of fetal well-being. A
fetal heartbeat is diagnostic for pregnancy and is detectable by Doppler around the 10th to 12th
week of gestation and by fetoscope at about the 17th to 20th week. Fetal movement, another
objective sign of pregnancy, is palpable around 20 weeks' gestation by a trained examiner;
pregnant women may experience movement subjectively, called quickening, around this same
time.
B) The earliest indicator of fetal viability is the beta subunit of human hCG measured in maternal
blood or urine. hCG normally rises at 10-12 weeks of gestation, and this initial elevation is
important in monitoring high-risk pregnancies where viability has not been documented. A lack
of increasing hCG levels, abnormally high levels of hCG, or an accelerated rise of hCG suggest
the need for further investigation of the pregnancy and of fetal well-being. A fetal heartbeat is
diagnostic for pregnancy and is detectable by Doppler around the 10th to 12th week of gestation
and by fetoscope at about the 17th to 20th week. Fetal movement, another objective sign of
pregnancy, is palpable around 20 weeks' gestation by a trained examiner; pregnant women may
experience movement subjectively, called quickening, around this same time.
C) The earliest indicator of fetal viability is the beta subunit of human hCG measured in maternal
blood or urine. hCG normally rises at 10-12 weeks of gestation, and this initial elevation is
important in monitoring high-risk pregnancies where viability has not been documented. A lack
of increasing hCG levels, abnormally high levels of hCG, or an accelerated rise of hCG suggest
the need for further investigation of the pregnancy and of fetal well-being. A fetal heartbeat is
diagnostic for pregnancy and is detectable by Doppler around the 10th to 12th week of gestation
and by fetoscope at about the 17th to 20th week. Fetal movement, another objective sign of
pregnancy, is palpable around 20 weeks' gestation by a trained examiner; pregnant women may
experience movement subjectively, called quickening, around this same time.
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D) The earliest indicator of fetal viability is the beta subunit of human hCG measured in
maternal blood or urine. hCG normally rises at 10-12 weeks of gestation, and this initial
elevation is important in monitoring high-risk pregnancies where viability has not been
documented. A lack of increasing hCG levels, abnormally high levels of hCG, or an accelerated
rise of hCG suggest the need for further investigation of the pregnancy and of fetal well-being. A
fetal heartbeat is diagnostic for pregnancy and is detectable by Doppler around the 10th to 12th
week of gestation and by fetoscope at about the 17th to 20th week. Fetal movement, another
objective sign of pregnancy, is palpable around 20 weeks' gestation by a trained examiner;
pregnant women may experience movement subjectively, called quickening, around this same
time.
Page Ref: 2035
Cognitive Level: Understanding
Learning Outcome: 5. Describe diagnostic and laboratory tests used to determine the individual's
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Exemplar 33.1 Antepartum Care
1) The spouse of a pregnant client tells the nurse that he is not sure he is ready to be a father and
wishes his wife had not gotten pregnant. Which response should the nurse make to the husband?
A) "Do you think you wife got pregnant on purpose, without your consent?"
B) "If you don't want the baby, it can be given up for adoption to another family."
C) "There are many ways that you can be of support to your wife at this time."
D) "Every husband has these feelings, and many times they never go away."
Answer: C
Explanation: A) The nurse needs to include the care of the father when providing care to a
pregnant client. The husband is expressing uncertainty about his ability to be a father and regrets
the pregnancy. The best response for the nurse to make that will support the client and husband is
to suggest ways that he can be of support to the client at this time. The nurse should not
minimize the husband's feelings by stating every husband has these feelings. It is inappropriate
for the nurse to say that the feelings may never go away. The nurse should not suggest that the
baby be given up for adoption or that the client became pregnant on purpose because neither of
these statements supports the client or husband at this time.
B) The nurse needs to include the care of the father when providing care to a pregnant client. The
husband is expressing uncertainty about his ability to be a father and regrets the pregnancy. The
best response for the nurse to make that will support the client and husband is to suggest ways
that he can be of support to the client at this time. The nurse should not minimize the husband's
feelings by stating every husband has these feelings. It is inappropriate for the nurse to say that
the feelings may never go away. The nurse should not suggest that the baby be given up for
adoption or that the client became pregnant on purpose because neither of these statements
supports the client or husband at this time.
C) The nurse needs to include the care of the father when providing care to a pregnant client. The
husband is expressing uncertainty about his ability to be a father and regrets the pregnancy. The
best response for the nurse to make that will support the client and husband is to suggest ways
that he can be of support to the client at this time. The nurse should not minimize the husband's
feelings by stating every husband has these feelings. It is inappropriate for the nurse to say that
the feelings may never go away. The nurse should not suggest that the baby be given up for
adoption or that the client became pregnant on purpose because neither of these statements
D) The nurse needs to include the care of the father when providing care to a pregnant client.
The husband is expressing uncertainty about his ability to be a father and regrets the pregnancy.
The best response for the nurse to make that will support the client and husband is to suggest
ways that he can be of support to the client at this time. The nurse should not minimize the
husband's feelings by stating every husband has these feelings. It is inappropriate for the nurse to
say that the feelings may never go away. The nurse should not suggest that the baby be given up
for adoption or that the client became pregnant on purpose because neither of these statements
Page Ref: 2038-2039
Learning Outcome: 1. Summarize the care needs of the pregnant client and her family.
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2) A client who recently learned of being pregnant tells the nurse that she stopped eating meat
years ago and started eating fish daily because it is healthier. What should the nurse instruct this
client?
A) Avoid shrimp, salmon, and catfish because these have higher mercury levels.
B) Eat up to 12 ounces a week of a variety of fish and shellfish.
C) Avoid albacore tuna because it has more mercury than other canned tuna.
D) Eat plenty of fish such as swordfish and shark while pregnant.
E) Follow a complete vegetarian diet while pregnant as an alternative to eating fish.
Answer: B, C
Explanation: A) Nearly all fish contain traces of mercury. Mercury can place the developing
nervous system of the fetus at risk and cause negative effects on cognitive functioning. The nurse
should instruct the client to eat up to 12 ounces a week of a variety of fish and shellfish. The
nurse should advise the client to avoid albacore tuna because it has more mercury than other
canned tuna. Swordfish and shark should be avoided because they contain high levels of
mercury. The nurse should not suggest that the client consume a complete vegetarian diet
because this could lead to other nutritional deficiencies. The nurse should encourage the client to
consume shrimp, salmon, and catfish, because these fish have the least amount of mercury.
B) Nearly all fish contain traces of mercury. Mercury can place the developing nervous system
of the fetus at risk and cause negative effects on cognitive functioning. The nurse should instruct
the client to eat up to 12 ounces a week of a variety of fish and shellfish. The nurse should advise
the client to avoid albacore tuna because it has more mercury than other canned tuna. Swordfish
and shark should be avoided because they contain high levels of mercury. The nurse should not
suggest that the client consume a complete vegetarian diet because this could lead to other
nutritional deficiencies. The nurse should encourage the client to consume shrimp, salmon, and
catfish, because these fish have the least amount of mercury.
C) Nearly all fish contain traces of mercury. Mercury can place the developing nervous system
D) Nearly all fish contain traces of mercury. Mercury can place the developing nervous system
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E) Nearly all fish contain traces of mercury. Mercury can place the developing nervous system of
the fetus at risk and cause negative effects on cognitive functioning. The nurse should instruct
Page Ref: 2096-2097
Learning Outcome: 2. Examine the potential impact of risk factors on pregnancy.
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3) A client at 16 weeks' gestation is diagnosed with tuberculosis. What should the nurse instruct
the client regarding the care needs for both the client and fetus?
A) Take Isoniazid as prescribed.
B) Contact with the baby after delivery will be limited for several months.
C) Take pyridoxine (vitamin B6) as prescribed.
D) No extra rest periods will be needed.
E) Take Rifampin as prescribed.
Answer: A, C
Explanation: A) When Isoniazid is used during pregnancy, supplemental pyridoxine (vitamin
B6) should also be taken. The client should also be instructed to plan for extra rest periods.
Rifampin crosses the placenta and will most likely not be prescribed for the client. Considering
the client is diagnosed with tuberculosis at 16 weeks' gestation, it is unlikely that the client will
not have any contact with the baby after delivery.
B) When Isoniazid is used during pregnancy, supplemental pyridoxine (vitamin B6) should also
be taken. The client should also be instructed to plan for extra rest periods. Rifampin crosses the
placenta and will most likely not be prescribed for the client. Considering the client is diagnosed
with tuberculosis at 16 weeks' gestation, it is unlikely that the client will not have any contact
with the baby after delivery.
C) When Isoniazid is used during pregnancy, supplemental pyridoxine (vitamin B6) should also
D) When Isoniazid is used during pregnancy, supplemental pyridoxine (vitamin B6) should also
E) When Isoniazid is used during pregnancy, supplemental pyridoxine (vitamin B6) should also
Page Ref: 2079
Learning Outcome: 6. Plan evidence-based care for a pregnant client and her family in
collaboration with other members of the healthcare team.
20
4) A client who is at 12 weeks' gestation is experiencing nausea, breast tenderness, and fatigue.
She tells the nurse her husband is upset with her constant complaints. Which nursing diagnosis
would be of the highest priority for the client at this time?
A) Ineffective Breastfeeding
B) Dysfunctional Family Processes
C) Nausea
D) Fatigue
Answer: C
Explanation: A) Of the three physiological complaints, the one that has the highest priority is
nausea because it could directly impact the developing fetus. Breast tenderness does not mean
that the client will experience ineffective breastfeeding. Fatigue is a common symptom of
pregnancy and would not negatively impact the developing fetus. The husband being upset with
the client's complaints does not necessarily mean that she and her husband have dysfunctional
family processes.
B) Of the three physiological complaints, the one that has the highest priority is nausea because
it could directly impact the developing fetus. Breast tenderness does not mean that the client will
experience ineffective breastfeeding. Fatigue is a common symptom of pregnancy and would not
negatively impact the developing fetus. The husband being upset with the client's complaints
does not necessarily mean that she and her husband have dysfunctional family processes.
C) Of the three physiological complaints, the one that has the highest priority is nausea because
D) Of the three physiological complaints, the one that has the highest priority is nausea because
Page Ref: 2107
Nursing Process: Diagnosis
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for the pregnant client.
21
5) While reviewing exercises to do when pregnant, a client of European descent tells the nurse
that she was taught never to reach over the head because this will harm the baby. What should
the nurse include in this client's plan of care?
A) Provide dietary instruction to ensure the client does not gain excessive weight.
B) Suggest limiting exercise to household chores.
C) Provide alternative activities to do instead of exercise.
D) Assure that reaching over the head will not harm the baby.
Answer: D
Explanation: A) Clients of European descent may believe that reaching over the head during
pregnancy can harm the baby. The nurse should assure the client that this is not accurate.
Providing activities to do instead of exercise will not address the misconception that reaching
over the head will harm the baby. Dietary instruction during pregnancy is important to ensure a
healthy weight gain for a healthy baby, not to ensure the client does not gain excessive weight
because of lack of exercise. There is not enough information to determine if the client should
limit exercise to household chores.
B) Clients of European descent may believe that reaching over the head during pregnancy can
harm the baby. The nurse should assure the client that this is not accurate. Providing activities to
do instead of exercise will not address the misconception that reaching over the head will harm
the baby. Dietary instruction during pregnancy is important to ensure a healthy weight gain for a
healthy baby, not to ensure the client does not gain excessive weight because of lack of exercise.
There is not enough information to determine if the client should limit exercise to household
chores.
C) Clients of European descent may believe that reaching over the head during pregnancy can
chores.
D) Clients of European descent may believe that reaching over the head during pregnancy can
chores.
Page Ref: 2076
Nursing Process: Planning
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care to the
pregnant client and her family.
22
6) Which statement indicates that instruction provided to a pregnant client and spouse about
amniocentesis was effective?
A) The client tells the spouse that the test has to be done before the 14th week of pregnancy.
B) The client tells the spouse that childbirth classes are not necessary if the baby has Down
syndrome.
C) The client and spouse state that it is not unusual for amniocentesis to misdiagnose a problem
with the baby.
D) The client and spouse state that the results of the amniocentesis will take up to 2 weeks.
Answer: D
Explanation: A) For couples having an amniocentesis, the first few months of pregnancy can be
difficult because the test cannot be performed until the 14th week of pregnancy, and not before.
The results of the amniocentesis will not be available for up to 2 weeks, which is evidence that
instruction regarding the test has been understood by the client and spouse. Childbirth classes are
important in promoting adaptation to the event of childbirth for expectant couples of any age or
situation. The results of an amniocentesis are 99% accurate in diagnosing genetic abnormalities.
B) For couples having an amniocentesis, the first few months of pregnancy can be difficult
because the test cannot be performed until the 14th week of pregnancy, and not before. The
results of the amniocentesis will not be available for up to 2 weeks, which is evidence that
C) For couples having an amniocentesis, the first few months of pregnancy can be difficult
D) For couples having an amniocentesis, the first few months of pregnancy can be difficult
Page Ref: 2089-2090
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for a pregnant client.
23
7) The nurse caring for a pregnant client experiencing nausea, vomiting, and heartburn should
instruct the client on which of the following?
A) Avoiding small meals and drinking fluids to limit nausea, vomiting, and heartburn
B) Having a dental checkup because pregnancy causes gum tenderness and swelling
C) How the physician can prescribe medication to treat the nausea, vomiting, and heartburn
D) Using herbal home remedies to control the nausea, vomiting, and heartburn
Answer: B
Explanation: A) The nurse should instruct the pregnant client to have a dental checkup because
pregnancy causes gum hypertrophy and tenderness. In addition, the client has experienced
nausea, vomiting, and heartburn. Each of these additional problems can impact dental health.
Herbal home remedies should be discouraged because most herbal remedies have not been
studied for potential harmful effects on the developing fetus. Telling the client that the physician
can prescribe medication to treat the nausea, vomiting, and heartburn would be providing
inaccurate information; the use of medication while pregnant can lead to birth defects. The nurse
should instruct the client to ingest small meals and drink fluids to prevent dehydration and poor
nutrition of the developing fetus.
B) The nurse should instruct the pregnant client to have a dental checkup because pregnancy
causes gum hypertrophy and tenderness. In addition, the client has experienced nausea, vomiting,
and heartburn. Each of these additional problems can impact dental health. Herbal home
remedies should be discouraged because most herbal remedies have not been studied for
potential harmful effects on the developing fetus. Telling the client that the physician can
prescribe medication to treat the nausea, vomiting, and heartburn would be providing inaccurate
information; the use of medication while pregnant can lead to birth defects. The nurse should
instruct the client to ingest small meals and drink fluids to prevent dehydration and poor nutrition
of the developing fetus.
C) The nurse should instruct the pregnant client to have a dental checkup because pregnancy
24
D) The nurse should instruct the pregnant client to have a dental checkup because pregnancy
Page Ref: 2075
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of the pregnant client.
25
8) What should the nurse instruct a pregnant client with a history of back pain regarding
childbirth exercises?
A) Perform the pelvic rock exercise only in the standing position.
B) Exercise in the supine position throughout the pregnancy.
C) Perform the pelvic rock exercise while in the hands and knees position.
D) Soak in a hot tub for approximately 30 minutes after exercise.
Answer: A
Explanation: A) The pelvic tilt or pelvic rock exercise helps prevent or reduce back strain as it
strengthens the abdominal muscles. The client with a history of back pain should be instructed to
perform the exercise in the standing position only. Doing the exercise on the hands and knees
may aggravate back strain and cause pain. Pregnant clients should be instructed to avoid
exercising in the supine position after the first trimester because it could hinder uterine blood
flow and harm the fetus. Pregnant clients should be instructed to avoid hot tubs because of the
possible teratogenic effects of hyperthermia on the developing fetus.
B) The pelvic tilt or pelvic rock exercise helps prevent or reduce back strain as it strengthens the
abdominal muscles. The client with a history of back pain should be instructed to perform the
exercise in the standing position only. Doing the exercise on the hands and knees may aggravate
back strain and cause pain. Pregnant clients should be instructed to avoid exercising in the supine
position after the first trimester because it could hinder uterine blood flow and harm the fetus.
Pregnant clients should be instructed to avoid hot tubs because of the possible teratogenic effects
of hyperthermia on the developing fetus.
C) The pelvic tilt or pelvic rock exercise helps prevent or reduce back strain as it strengthens the
D) The pelvic tilt or pelvic rock exercise helps prevent or reduce back strain as it strengthens the
Page Ref: 2069
Learning Outcome: 6. Plan evidence-based care for a pregnant client and her family in
26
9) A client in her 5th month of pregnancy who is attending an antepartum clinic remarks to the
nurse that her long-standing chronic disease has markedly improved since she's been pregnant.
What teaching would the nurse provide about conditions that often go into remission during the
antepartum period?
A) "Systemic lupus erythematosus (SLE) is often difficult to diagnose; perhaps because you are
improving during pregnancy this diagnosis was made in error and should be revisited."
B) "Rheumatoid arthritis (RA) tends to go into remission during pregnancy; unfortunately,
relapses typically occur in the postpartum period."
C) "For whatever reason, having HIV during pregnancy leads to a remission of signs and
symptoms and, thankfully, helps to stall the progression of the disease, including following
delivery."
D) "Medical researchers aren't sure why signs and symptoms of multiple sclerosis often get
better during pregnancy, but be aware that there also tends to be a slight increase in relapse rates
after delivery."
E) "Women with epilepsy who have frequent seizures often find that their level of seizure
activity significantly improves during pregnancy, but then seizure episodes tend to return to pre-
pregnancy levels."
Answer: B, D
Explanation: A) Multiple sclerosis (MS) and rheumatoid arthritis (RA) are autoimmune-related
chronic conditions that often go into remission during pregnancy. Systemic lupus erythematosus
(SLE) is characterized by exacerbations and remissions, but pregnancy is unassociated with
remission. Being pregnant while infected with HIV doesn't cause a remission of signs and
symptoms of this chronic disease, but neither is pregnancy likely to accelerate the progression of
HIV. Although many women with epilepsy have uneventful pregnancies with excellent
outcomes, those with a history of frequent seizures before pregnancy may have an exacerbation
of seizure activity during gestation.
B) Multiple sclerosis (MS) and rheumatoid arthritis (RA) are autoimmune-related chronic
conditions that often go into remission during pregnancy. Systemic lupus erythematosus (SLE) is
characterized by exacerbations and remissions, but pregnancy is unassociated with remission.
Being pregnant while infected with HIV doesn't cause a remission of signs and symptoms of this
chronic disease, but neither is pregnancy likely to accelerate the progression of HIV. Although
many women with epilepsy have uneventful pregnancies with excellent outcomes, those with a
history of frequent seizures before pregnancy may have an exacerbation of seizure activity
during gestation.
C) Multiple sclerosis (MS) and rheumatoid arthritis (RA) are autoimmune-related chronic
during gestation.
27
D) Multiple sclerosis (MS) and rheumatoid arthritis (RA) are autoimmune-related chronic
during gestation.
E) Multiple sclerosis (MS) and rheumatoid arthritis (RA) are autoimmune-related chronic
during gestation.
Page Ref: 2079
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care to the
pregnant client and her family.
28
10) A clinic nurse who works in a community health clinic is reviewing the immunization status
of a young woman whose parents were opposed to childhood vaccination. The client and her
partner have been trying to conceive, and the woman admits that she's worried about how her
lack of immunizations might affect her unborn child and any children she might have. Given her
interest in reducing the risk of childhood diseases through vaccination, what vaccine would the
nurse absolutely recommend that this client not receive at this time?
A) Pertussis vaccine
B) Annual influenza vaccine
C) Rubella
D) Tetanus
Answer: C
Explanation: A) Rubella vaccine should never be given to pregnant women (or women trying to
conceive) because the vaccine contains the attenuated live virus, which has teratogenic effects on
the developing fetus. Pertussis and tetanus vaccines, as well as the annual influenza vaccine, can
safely be given in pregnancy. Safe vaccine recommendations for pregnant women are available
from the Centers for Disease Control and Prevention website (http://www.cdc.gov).
B) Rubella vaccine should never be given to pregnant women (or women trying to conceive)
because the vaccine contains the attenuated live virus, which has teratogenic effects on the
developing fetus. Pertussis and tetanus vaccines, as well as the annual influenza vaccine, can
C) Rubella vaccine should never be given to pregnant women (or women trying to conceive)
D) Rubella vaccine should never be given to pregnant women (or women trying to conceive)
Page Ref: 2072
Learning Outcome: 2. Examine the potential impact of risk factors on pregnancy.
29
Exemplar 33.2 Intrapartum Care
1) The nulliparous client asks the nurse why the cervix has only dilated from 1 to 2 cm in 3 hours
of contractions, occurring every 5 minutes. What is the best response by the nurse?
A) "When your perineal body thins out, your cervix will begin to dilate much faster than it is
now."
B) "The hormones that cause labor to begin are just getting to the levels that will change your
cervix."
C) "What did you expect? You've only had contractions for a few hours. Labor takes time."
D) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor
progress."
Answer: D
Explanation: A) Cervical effacement must be nearly complete before cervical dilation takes
place in primiparas. This is why the labor and birth of a first baby usually take much more time
than for subsequent labor and births. The perineal body thinning primarily occurs during the
second stage of labor; it is not expected early in labor. The reply "what did you expect" is not
therapeutic. Although it is true that this client has only been in early labor for a short time, and it
is true that labor for a nullipara averages 12-24 hours, the nurse must always be therapeutic in all
communication. The hormones that cause labor contractions do not directly cause cervical
change; the contractions cause the cervix to change.
B) Cervical effacement must be nearly complete before cervical dilation takes place in
primiparas. This is why the labor and birth of a first baby usually take much more time than for
subsequent labor and births. The perineal body thinning primarily occurs during the second stage
of labor; it is not expected early in labor. The reply "what did you expect" is not therapeutic.
Although it is true that this client has only been in early labor for a short time, and it is true that
labor for a nullipara averages 12-24 hours, the nurse must always be therapeutic in all
C) Cervical effacement must be nearly complete before cervical dilation takes place in
30
D) Cervical effacement must be nearly complete before cervical dilation takes place in
Page Ref: 2122
Learning Outcome: 1. Describe the pathophysiology and clinical manifestations associated with
normal labor and delivery.
31
2) During the fourth stage of labor, a client's blood pressure is 110/60, pulse 90, and the fundus is
firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority
action of the nurse?
A) Massage the fundus.
B) Turn the client onto the left side.
C) Place the bed in the Trendelenburg position.
D) Continue to monitor.
Answer: D
Explanation: A) The client's assessment data are normal for the fourth stage of labor, so
monitoring is the only action necessary. During the fourth stage of labor, the mother experiences
a slight drop in blood pressure and a slightly increased pulse. A left lateral position is not
necessary with a BP of 110/60 and a pulse of 90. The Trendelenburg position is not necessary
with a BP of 110/60 and a pulse of 90. The uterus should be midline and firm; massage is not
necessary.
B) The client's assessment data are normal for the fourth stage of labor, so monitoring is the only
action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood
pressure and a slightly increased pulse. A left lateral position is not necessary with a BP of
110/60 and a pulse of 90. The Trendelenburg position is not necessary with a BP of 110/60 and a
pulse of 90. The uterus should be midline and firm; massage is not necessary.
C) The client's assessment data are normal for the fourth stage of labor, so monitoring is the only
D) The client's assessment data are normal for the fourth stage of labor, so monitoring is the only
Page Ref: 2126
Learning Outcome: 2. Identify risk factors and prevention methods associated with normal labor
and delivery.
32
3) The nurse is instructing a pregnant adolescent client on how the baby's condition is evaluated
during labor. The nurse knows that education was successful when the client states which of the
following?
A) "During labor, the nurse will verify that my contractions are strong but not too close
together."
B) "During labor, the nurse will look at the color and amount of bloody show that I have."
C) "During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor."
D) "During labor, the nurse will check my cervix by doing a pelvic exam every two hours."
Answer: C
Explanation: A) During labor, the nurse will assess the baby's heart rate with an electronic fetal
monitor. This is the statement the client should make to prove that education was successful.
Although cervical exams are performed on a regular basis, the pelvic exam does not assess fetal
status. The client was asked specifically about assessing fetal status in labor.
Although bloody show is monitored, doing so does not assess fetal status. Although contraction
strength is palpated abdominally, the client was asked about assessing fetal status in labor.
B) During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor. This
is the statement the client should make to prove that education was successful. Although cervical
exams are performed on a regular basis, the pelvic exam does not assess fetal status. The client
was asked specifically about assessing fetal status in labor.
C) During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor. This
D) During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor. This
Page Ref: 2148
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for a woman during labor and delivery.
33
4) A client in the fourth stage of labor is crying out in pain. Which nursing diagnosis would be
the most appropriate for the client at this time?
A) Health-Seeking Behaviors
B) Fear
C) Anxiety
D) Acute Pain
Answer: D
Explanation: A) In the fourth stage of labor, the diagnosis of Acute Pain, which could be related
to perineal trauma, is the most appropriate for the client at this time. The diagnoses of Fear and
Anxiety would be appropriate during the first stage of labor. The diagnosis of Health-Seeking
Behaviors does not address the client experiencing pain during labor.
B) In the fourth stage of labor, the diagnosis of Acute Pain, which could be related to perineal
trauma, is the most appropriate for the client at this time. The diagnoses of Fear and Anxiety
would be appropriate during the first stage of labor. The diagnosis of Health-Seeking Behaviors
does not address the client experiencing pain during labor.
C) In the fourth stage of labor, the diagnosis of Acute Pain, which could be related to perineal
D) In the fourth stage of labor, the diagnosis of Acute Pain, which could be related to perineal
Page Ref: 2156
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for a woman during
labor and delivery.
34
5) The labor and delivery nurse is planning care needs for clients in labor. Which client is the
priority for further intervention?
A) Nullipara at 10 cm and pushing, external fetal monitor applied
B) Nullipara in preterm labor, external monitor in place
C) Multipara at 7 cm, fetal heart tones auscultated every 90 minutes
D) Multipara with meconium-stained fluid, internal fetal scalp electrode in use
Answer: C
Explanation: A) During active labor, the fetal heart tones should be auscultated every 30
minutes; every 90 minutes is too infrequent. This is the client who should receive further
intervention first. External monitoring can be used instead of auscultation of the fetal heart tones
during labor for the nullipara at 10 cm and pushing. Meconium-stained amniotic fluid is not an
expected finding; however, internal fetal monitoring with the internal fetal scalp electrode is
often utilized when meconium-stained amniotic fluid is present. This client is being treated
appropriately and would not need intervention first. External monitoring during preterm labor
will assess both contractions and fetal status, so the nullipara in preterm labor will not be the
priority for intervention.
B) During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90
minutes is too infrequent. This is the client who should receive further intervention first. External
monitoring can be used instead of auscultation of the fetal heart tones during labor for the
nullipara at 10 cm and pushing. Meconium-stained amniotic fluid is not an expected finding;
however, internal fetal monitoring with the internal fetal scalp electrode is often utilized when
meconium-stained amniotic fluid is present. This client is being treated appropriately and would
not need intervention first. External monitoring during preterm labor will assess both
contractions and fetal status, so the nullipara in preterm labor will not be the priority for
intervention.
C) During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90
intervention.
35
D) During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90
intervention.
Page Ref: 2164
Learning Outcome: 6. Plan evidence-based care for a woman during labor and delivery and her
family members in collaboration with other members of the healthcare team.
36
6) Upon delivery of the newborn, the nursing intervention that most promotes parental
attachment is which of the following?
A) Placing the newborn under the radiant warmer
B) Placing the newborn on the bed next to the mother
C) Placing the newborn on the maternal abdomen
D) Taking the newborn to the nursery for the initial assessment
Answer: C
Explanation: A) Placing the baby on the maternal abdomen promotes attachment and bonding
and gives the mother a chance to interact immediately with her baby. Removing the baby to the
radiant warmer does not promote interaction. Allowing the mother a chance to rest immediately
after delivery does not promote interaction. Taking the newborn to the nursery for the initial
assessment does not promote interaction.
B) Placing the baby on the maternal abdomen promotes attachment and bonding and gives the
mother a chance to interact immediately with her baby. Removing the baby to the radiant warmer
does not promote interaction. Allowing the mother a chance to rest immediately after delivery
does not promote interaction. Taking the newborn to the nursery for the initial assessment does
not promote interaction.
C) Placing the baby on the maternal abdomen promotes attachment and bonding and gives the
D) Placing the baby on the maternal abdomen promotes attachment and bonding and gives the
Page Ref: 2135
Learning Outcome: 7. Evaluate expected outcomes for a pregnant woman and her newborn
during the intrapartum period.
37
7) A client in labor with the fetus in the vertex position has a spontaneous rupture of membranes.
The nurse sees that the amniotic fluid is meconium-stained and immediately takes what action?
A) Notifies the physician that birth is imminent
B) Changes the client's position in bed
C) Begins continuous fetal heart rate monitoring
D) Administers oxygen at 2 liters per minute
Answer: C
Explanation: A) Meconium-stained amniotic fluid is an abnormal fetal finding and is an
indication for continuous fetal monitoring. Changing the client's position is not indicated.
Meconium-stained amniotic fluid does not indicate that birth is imminent. Oxygen administration
is not indicated.
B) Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for
continuous fetal monitoring. Changing the client's position is not indicated. Meconium-stained
amniotic fluid does not indicate that birth is imminent. Oxygen administration is not indicated.
C) Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for
D) Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for
Page Ref: 2138
care of a pregnant woman during labor and delivery.
38
8) The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are
present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at
120 bpm by the end of the contraction. What nursing action is best?
A) Document the fetal heart rate.
B) Prepare for imminent delivery.
C) Apply oxygen via mask at 10 liters.
D) Assist the client into the Fowler's position.
Answer: A
Explanation: A) The described fetal heart rate has a normal baseline, the presence of
accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No
intervention is necessary. The fetal heart rate tracing is normal; oxygen is not indicated. There is
no indication that delivery will be occurring soon. The fetal heart rate tracing is normal, no
intervention is necessary. The client does not need to be assisted into the Fowler's position.
B) The described fetal heart rate has a normal baseline, the presence of accelerations indicates
adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary. The
fetal heart rate tracing is normal; oxygen is not indicated. There is no indication that delivery will
be occurring soon. The fetal heart rate tracing is normal, no intervention is necessary. The client
does not need to be assisted into the Fowler's position.
C) The described fetal heart rate has a normal baseline, the presence of accelerations indicates
D) The described fetal heart rate has a normal baseline, the presence of accelerations indicates
Page Ref: 2145
Learning Outcome: 6. Plan evidence-based care for a woman during labor and delivery and her
family members in collaboration with other members of the healthcare team.
39
9) A pregnant woman presents to the Emergency Department and reports that she has started
labor and is certain the baby is coming "any minute now" and asks to be taken up to the delivery
suite. The nurse assigned to provide care for this woman over a couple of hours determines that
the woman is in "false" labor and is preparing her to return home. Which observation or
observations support this conclusion?
A) The contractions do not have a regular pattern.
B) Her cervix has dilated 2 cm over the 2 hours of observation.
C) The frequency and intensity of the contractions have stayed about the same.
D) Walking seems to increase the strength of the contractions.
E) The contractions are mostly in her abdomen.
Answer: A, C, E
Explanation: A) Signs and symptoms of "false" labor, in contrast to "true" labor, include a
pattern of irregular contractions that do not increase in frequency or intensity, a lack of cervical
dilation and effacement, discomfort that is felt mostly in the abdomen rather than in the back and
radiating to the front, and the fact that activity does not increase contraction intensity.
B) Signs and symptoms of "false" labor, in contrast to "true" labor, include a pattern of irregular
contractions that do not increase in frequency or intensity, a lack of cervical dilation and
effacement, discomfort that is felt mostly in the abdomen rather than in the back and radiating to
the front, and the fact that activity does not increase contraction intensity.
C) Signs and symptoms of "false" labor, in contrast to "true" labor, include a pattern of irregular
D) Signs and symptoms of "false" labor, in contrast to "true" labor, include a pattern of irregular
E) Signs and symptoms of "false" labor, in contrast to "true" labor, include a pattern of irregular
Page Ref: 2121
Learning Outcome: 7. Evaluate expected outcomes for a pregnant client.
40
10) The nurse on an obstetric unit is caring for a client who has asthma. The client has a cold and
has an exacerbation of asthma symptoms, including mild wheezing. To help avoid hypoxia-
related complications in the fetus, what medication is likely to be used to treat her symptoms?
A) IV corticosteroid (e.g., prednisone)
B) Oral pseudoephedrine (e.g., Sudafed)
C) Inhaled beta2-agonist (e.g., albuterol)
D) Oral acetylsalicylic acid (e.g., aspirin)
Answer: C
Explanation: A) Albuterol, a beta2-agonist, is the medication recommended to treat asthma
exacerbations during pregnancy. Steroids, decongestants such as pseudoephedrine, and aspirin
should be avoided in pregnancy because of potential harmful effects to the fetus.
B) Albuterol, a beta2-agonist, is the medication recommended to treat asthma exacerbations
during pregnancy. Steroids, decongestants such as pseudoephedrine, and aspirin should be
avoided in pregnancy because of potential harmful effects to the fetus.
C) Albuterol, a beta2-agonist, is the medication recommended to treat asthma exacerbations
D) Albuterol, a beta2-agonist, is the medication recommended to treat asthma exacerbations
Page Ref: 2129
care of a pregnant woman during labor and delivery.
41
Exemplar 33.3 Postpartum Care
1) During an assessment, the nurse notes the postpartum client is experiencing intense shaking
chills. What does this assessment finding indicate to the nurse?
A) This is evidence of incomplete expulsion of the placenta.
B) The client has a full bladder.
C) This may be a reaction to maternal adrenal production during labor and birth.
D) This may be a reaction to epidural anesthesia.
E) The client has a fever from a postpartum infection.
Answer: C, D
Explanation: A) Intense tremors similar to shaking chills can occur in the mother after birth and
have been explained as being caused by a reaction to epidural anesthesia or a reaction to
maternal adrenal production during labor and birth. The nurse would need to assess the client's
temperature to determine the presence of a fever. Indications of a full bladder would most likely
be a displaced uterus. Shaking chills after delivery is not evidence of incomplete expulsion of the
placenta.
B) Intense tremors similar to shaking chills can occur in the mother after birth and have been
explained as being caused by a reaction to epidural anesthesia or a reaction to maternal adrenal
production during labor and birth. The nurse would need to assess the client's temperature to
determine the presence of a fever. Indications of a full bladder would most likely be a displaced
uterus. Shaking chills after delivery is not evidence of incomplete expulsion of the placenta.
C) Intense tremors similar to shaking chills can occur in the mother after birth and have been
D) Intense tremors similar to shaking chills can occur in the mother after birth and have been
E) Intense tremors similar to shaking chills can occur in the mother after birth and have been
Page Ref: 2175
Learning Outcome: 1. Describe the pathophysiology and clinical manifestations associated with
the postpartum period.
42
2) During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago,
the nurse assesses the following: fundus firm and at the umbilicus, and moderate lochia rubra
with a steady trickle of blood noted from the vagina. The nurse determines that which assessment
finding needs follow up?
A) Moderate lochia rubra
B) Steady trickle of blood
C) Fundus at the umbilical level
D) Firm fundus
Answer: B
Explanation: A) The steady trickle of blood could indicate a laceration in the birth canal and
should be reported to the healthcare provider for follow up. A firm fundus is a desired finding
and is considered normal. Six hours after birth, the fundus at the umbilicus would not be a
concern. Moderate lochia rubra is considered a normal finding.
B) The steady trickle of blood could indicate a laceration in the birth canal and should be
reported to the healthcare provider for follow up. A firm fundus is a desired finding and is
considered normal. Six hours after birth, the fundus at the umbilicus would not be a concern.
Moderate lochia rubra is considered a normal finding.
C) The steady trickle of blood could indicate a laceration in the birth canal and should be
D) The steady trickle of blood could indicate a laceration in the birth canal and should be
Page Ref: 2130
Learning Outcome: 2. Identify risk factors and prevention methods associated with the
postpartum period.
43
3) The nurse is providing postpartum care to a client from a different culture. What actions
should the nurse take when planning care for this client?
A) Assess for any assistance required during breastfeeding.
B) Ask if there are any specific customs the client wants to follow.
C) Assess for any specific foods or fluids to hasten recovery.
D) Limit visitors.
E) Restrict interactions.
Answer: A, B, C
Explanation: A) When providing postpartum care to a client of a different culture, the nurse
should assess for any specific customs the client wants to follow, if there are any foods or fluids
in the culture that are believed to hasten recovery, and if the client requires any assistance during
breastfeeding. Restricting visitors would not support the postpartum client's needs. Restricting
interactions would not support the client's physiologic or psychological needs.
B) When providing postpartum care to a client of a different culture, the nurse should assess for
any specific customs the client wants to follow, if there are any foods or fluids in the culture that
are believed to hasten recovery, and if the client requires any assistance during breastfeeding.
Restricting visitors would not support the postpartum client's needs. Restricting interactions
would not support the client's physiologic or psychological needs.
C) When providing postpartum care to a client of a different culture, the nurse should assess for
D) When providing postpartum care to a client of a different culture, the nurse should assess for
E) When providing postpartum care to a client of a different culture, the nurse should assess for
Page Ref: 2156-2157
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for postpartum clients.
44
4) A client who gave birth to her first child 12 hours ago has the following assessment findings:
nauseated but has not vomited for 2 hours; boggy fundus that firmed with massage; moderately
heavy lochia rubra; ecchymotic and edematous perineum; and pain rating of 6 on scale of 1-10.
Her partner is present and supportive. Breastfeeding has been successful three times. Which
nursing diagnosis has the highest priority for this client?
A) Acute Pain related to perineal trauma
B) Risk for Deficient Fluid Volume secondary to boggy fundus and nausea
C) Deficient Knowledge related to birth of first child
D) Readiness for Enhanced Family Coping related to partner involvement
Answer: B
Explanation: A) Fluid volume is a critical physical issue and is therefore the highest-priority
nursing diagnosis. Although the nursing diagnosis of Acute Pain fits, it is a lower priority than
the risk of fluid volume deficit. Although the nursing diagnosis of Readiness for Enhanced
Family Coping fits, it is a lower priority than the risk of fluid volume deficit. Although the
nursing diagnosis of Deficient Knowledge fits, a knowledge deficit is a psychosocial issue and
therefore a much lower priority than the critical physical diagnosis of risk for deficient fluid
volume.
B) Fluid volume is a critical physical issue and is therefore the highest-priority nursing
diagnosis. Although the nursing diagnosis of Acute Pain fits, it is a lower priority than the risk of
fluid volume deficit. Although the nursing diagnosis of Readiness for Enhanced Family Coping
fits, it is a lower priority than the risk of fluid volume deficit. Although the nursing diagnosis of
Deficient Knowledge fits, a knowledge deficit is a psychosocial issue and therefore a much
lower priority than the critical physical diagnosis of risk for deficient fluid volume.
C) Fluid volume is a critical physical issue and is therefore the highest-priority nursing
D) Fluid volume is a critical physical issue and is therefore the highest-priority nursing
Page Ref: 2182
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for the postpartum
client.
45
5) The nurse is planning care for a client who had a cesarean birth 4 hours ago. What should be
included in this client's plan of care?
A) Encourage the use of breathing, relaxation, and distraction.
B) Encourage deep breathing and coughing every 2 to 4 hours.
C) Encourage to ambulate to the bathroom to void.
D) Discourage leg exercises.
E) Withhold all analgesics.
Answer: A, B
Explanation: A) Encouraging deep breathing and coughing every 2 to 4 hours and encouraging
the use of breathing, relaxation, and distraction all address the client's nursing care needs, which
are similar to those of other surgical clients. Encouraging the client to ambulate to the bathroom
to void might be an intervention done on the first or second day postpartum, but not in the first 4
hours. Leg exercises should be encouraged. Withholding analgesics may leave the client in pain.
B) Encouraging deep breathing and coughing every 2 to 4 hours and encouraging the use of
breathing, relaxation, and distraction all address the client's nursing care needs, which are similar
to those of other surgical clients. Encouraging the client to ambulate to the bathroom to void
might be an intervention done on the first or second day postpartum, but not in the first 4 hours.
Leg exercises should be encouraged. Withholding analgesics may leave the client in pain.
C) Encouraging deep breathing and coughing every 2 to 4 hours and encouraging the use of
D) Encouraging deep breathing and coughing every 2 to 4 hours and encouraging the use of
E) Encouraging deep breathing and coughing every 2 to 4 hours and encouraging the use of
Page Ref: 2183
Learning Outcome: 6. Plan evidence-based care for a postpartum client and her family in
46
6) The nurse is instructing a postpartum client on when she can resume her normal exercise
regimen of running for exercise most days of the week. Which statement indicates that teaching
was effective?
A) "I can start running in 2 weeks and breastfeed the baby when I return."
B) "I will not be able to run because it is not recommended for breastfeeding women."
C) "I can run if I get 8 hours of sleep per day."
D) "I should check my energy level at home and increase my activity slowly."
Answer: D
Explanation: A) Checking the energy level and increasing activity slowly is the correct response
because when energy returns, activity can be increased. Increasing activity slowly is safer and
less likely to cause injury than starting off running long distances. Running might be feasible at 2
weeks, but it will depend upon the client's energy level. Breastfeeding should take place just
prior to running to minimize chest discomfort. The inability to run because of breastfeeding is
not a true statement; it is more comfortable to nurse prior to running, but running is not
contraindicated. The need to have 8 hours of sleep before running is not a true statement; not all
clients who get a total of 8 hours of sleep feel rested, because sleep can be interrupted.
B) Checking the energy level and increasing activity slowly is the correct response because when
energy returns, activity can be increased. Increasing activity slowly is safer and less likely to
cause injury than starting off running long distances. Running might be feasible at 2 weeks, but it
will depend upon the client's energy level. Breastfeeding should take place just prior to running
to minimize chest discomfort. The inability to run because of breastfeeding is not a true
statement; it is more comfortable to nurse prior to running, but running is not contraindicated.
The need to have 8 hours of sleep before running is not a true statement; not all clients who get a
total of 8 hours of sleep feel rested, because sleep can be interrupted.
C) Checking the energy level and increasing activity slowly is the correct response because when
D) Checking the energy level and increasing activity slowly is the correct response because when
Page Ref: 2186
Learning Outcome: 7. Evaluate expected outcomes for the postpartum client.
47
7) A postpartum client is experiencing pain from an episiotomy. What can the nurse instruct this
client to aid with pain relief?
A) Wash the area with soap and water every day.
B) Tighten the buttocks before sitting.
C) Change peripads daily.
D) Perform leg scissor kicks several times a day.
E) Increase the intake of meat, cheese, fish, eggs, and nuts.
Answer: B, E
Explanation: A) Lysine has been identified as an essential amino acid that decreases the pain of
an episiotomy. This amino acid is present in meat, cheese, fish, eggs, and nuts. The nurse should
instruct the client to tighten the buttocks before sitting to reduce the pain. To prevent infection,
not to reduce pain, the client should wash the area daily and the peripad should be changed four
times a day. Performing leg scissor kick exercises would put strain on the incision site and
should not be done.
B) Lysine has been identified as an essential amino acid that decreases the pain of an episiotomy.
This amino acid is present in meat, cheese, fish, eggs, and nuts. The nurse should instruct the
client to tighten the buttocks before sitting to reduce the pain. To prevent infection, not to reduce
pain, the client should wash the area daily and the peripad should be changed four times a day.
Performing leg scissor kick exercises would put strain on the incision site and should not be
done.
C) Lysine has been identified as an essential amino acid that decreases the pain of an episiotomy.
done.
D) Lysine has been identified as an essential amino acid that decreases the pain of an episiotomy.
done.
E) Lysine has been identified as an essential amino acid that decreases the pain of an episiotomy.
done.
Page Ref: 2184
Learning Outcome: 5. Summarize therapies used by disciplinary teams in the collaborative care
of a postpartum client.
48
8) A postpartum client who delivered 4 hours ago and has a mediolateral episiotomy and large
hemorrhoids is rating her pain at 7 on a scale of 1-10. She has a history of anaphylactic reaction
to acetaminophen (Tylenol). Which nursing action would be best?
A) Encourage use of benzocaine topical anesthetic spray (Dermoplast).
B) Provide 2 oxycodone with acetaminophen (Percocet) by mouth.
C) Offer the client 800 mg ibuprofen (Advil) orally with food.
D) Run very warm water into the tub and assist her into the bath.
Answer: C
Explanation: A) Offering ibuprofen (Advil) is the best option because the client is experiencing
moderately severe pain with inflammation. Ibuprofen is a nonsteroidal anti-inflammatory drug
that both reduces inflammation and provides pain relief. Oxycodone with acetaminophen
(Percocet) is contraindicated because of the client's allergic reaction to acetaminophen. Topical
anesthetic sprays such as Dermoplast can be a helpful adjunct in pain relief but are not sufficient
when a client has moderately severe pain. Ice packs instead of a warm bath would be better at
this stage, because they will cause vasoconstriction to reduce edema and pain relief.
B) Offering ibuprofen (Advil) is the best option because the client is experiencing moderately
severe pain with inflammation. Ibuprofen is a nonsteroidal anti-inflammatory drug that both
reduces inflammation and provides pain relief. Oxycodone with acetaminophen (Percocet) is
contraindicated because of the client's allergic reaction to acetaminophen. Topical anesthetic
sprays such as Dermoplast can be a helpful adjunct in pain relief but are not sufficient when a
client has moderately severe pain. Ice packs instead of a warm bath would be better at this stage,
because they will cause vasoconstriction to reduce edema and pain relief.
C) Offering ibuprofen (Advil) is the best option because the client is experiencing moderately
D) Offering ibuprofen (Advil) is the best option because the client is experiencing moderately
Page Ref: 2187
49
9) In palpating the fundus of a woman on her first day postpartum, the nurse finds that the
woman's uterus is higher than expected and is deviated to the right. She is not having excessive
uterine bleeding. What action should the nurse take first?
A) Contact the client's nurse midwife to notify the midwife of this condition.
B) Have a nursing colleague reexamine the client to verify the nurse's finding.
C) Have the client void to empty the bladder and then remeasure fundal height.
D) Catheterize the woman to empty the bladder and then remeasure fundal height.
Answer: C
Explanation: A) The cause of a distended fundus in a recently delivered woman is likely due to a
distended bladder causing a temporary upward displacement of the uterus. Having the woman
empty her bladder and then remeasuring the height of the fundus is the first action for the nurse
to take at this time. If the client is unable to void, an in and out catheterization to empty the
bladder is indicated, after which fundal height would then be reassessed. The fact that the client
is not having excessive uterine bleeding suggests that fundal displacement is not due to uterine
bleeding, a serious complication that would require notification of the midwife or medical care
provider. Also, the first action would generally not be to have a colleague re-check the nurse's
finding, but to have the client relieve pressure on the uterus by voiding.
B) The cause of a distended fundus in a recently delivered woman is likely due to a distended
bladder causing a temporary upward displacement of the uterus. Having the woman empty her
bladder and then remeasuring the height of the fundus is the first action for the nurse to take at
this time. If the client is unable to void, an in and out catheterization to empty the bladder is
indicated, after which fundal height would then be reassessed. The fact that the client is not
having excessive uterine bleeding suggests that fundal displacement is not due to uterine
C) The cause of a distended fundus in a recently delivered woman is likely due to a distended
50
D) The cause of a distended fundus in a recently delivered woman is likely due to a distended
Page Ref: 2168
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for a postpartum client.
51
10) Nurses caring for clients in labor anticipating a vaginal birth after cesarean (VBAC) typically
would want to verify that orders are in place to obtain a blood count, type, and screen on
admission, to insert a heparin lock for IV access if needed, to provide continuous electronic fetal
monitoring, and to allow clear fluids. What additional care actions are generally required for
women expecting a VBAC whose previous birthing history places them at higher risk (e.g., had a
previous caesarean birth and other than a low transverse uterine incision)?
A) Maintaining NPO status
B) Limiting visitors in the labor room to one individual
C) Verifying that the woman has no allergies to any drugs
D) Placing a urinary catheter to more accurately measure urinary output
E) Insertion of an intrauterine catheter to monitor intrauterine pressure during labor
Answer: A, E
Explanation: A) Protocols for the care of low-risk women with previous surgical deliveries who
are anticipating a vaginal birth after caesarian (VBAC) may be individualized by each facility,
but generally include blood work (count, typing, and screening), insertion of a heparin lock to
ensure IV access if needed, use of electronic fetal monitoring, and a clear fluid diet. In general,
those who are at higher risk (e.g., have had a previous caesarean birth and other than low
transverse uterine incision) are typically kept on NPO status and have an intrauterine catheter
inserted to monitor intrauterine pressure during labor. Limiting visitors to one individual and
routinely placing a urinary catheter in these clients are also not indicated. Assessing drug
allergies is done on all hospital admissions, not for just high-risk VBAC clients.
B) Protocols for the care of low-risk women with previous surgical deliveries who are
anticipating a vaginal birth after caesarian (VBAC) may be individualized by each facility, but
generally include blood work (count, typing, and screening), insertion of a heparin lock to ensure
IV access if needed, use of electronic fetal monitoring, and a clear fluid diet. In general, those
who are at higher risk (e.g., have had a previous caesarean birth and other than low transverse
uterine incision) are typically kept on NPO status and have an intrauterine catheter inserted to
monitor intrauterine pressure during labor. Limiting visitors to one individual and routinely
placing a urinary catheter in these clients are also not indicated. Assessing drug allergies is done
on all hospital admissions, not for just high-risk VBAC clients.
C) Protocols for the care of low-risk women with previous surgical deliveries who are
52
D) Protocols for the care of low-risk women with previous surgical deliveries who are
E) Protocols for the care of low-risk women with previous surgical deliveries who are
Page Ref: 2135
53
Exemplar 33.4 Newborn Care
1) Which assessment data would be of the greatest concern in a sleeping 1-hour-old newborn of
39 weeks' gestation?
A) Respirations of 68 per minute
B) Temperature of 97.9°F
C) Blood pressure of 72/44 mmHg
D) Acrocyanosis present
E) Heart rate of 166 bpm
Answer: A, E
Explanation: A) Normal respiratory rate in a 1-hour-old newborn is 40-60 per minute. The rate
of 68 per minute could represent a less-than-expected transition to extrauterine life.
Acrocyanosis is present in 85% of newborns at 1 minute after birth. The newborn who continues
to have acrocyanosis 1 hour after birth is not an expected finding and should be reported. A
temperature of 97.7°F is within the normal temperature range of 97.5-99°F. The blood pressure
of 72/44 mmHg is within the normal range of 90-60/50-40 mmHg. The heart rate of 166 bpm is
within the normal range of 120-160 bpm.
B) Normal respiratory rate in a 1-hour-old newborn is 40-60 per minute. The rate of 68 per
minute could represent a less-than-expected transition to extrauterine life. Acrocyanosis is
present in 85% of newborns at 1 minute after birth. The newborn who continues to have
acrocyanosis 1 hour after birth is not an expected finding and should be reported. A temperature
of 97.7°F is within the normal temperature range of 97.5-99°F. The blood pressure of 72/44
mmHg is within the normal range of 90-60/50-40 mmHg. The heart rate of 166 bpm is within the
normal range of 120-160 bpm.
C) Normal respiratory rate in a 1-hour-old newborn is 40-60 per minute. The rate of 68 per
D) Normal respiratory rate in a 1-hour-old newborn is 40-60 per minute. The rate of 68 per
54
E) Normal respiratory rate in a 1-hour-old newborn is 40-60 per minute. The rate of 68 per
Page Ref: 2194
Learning Outcome: 1. Describe the normal physiologic adaptations of the newborn to
extrauterine life.
2) The nurse has received a shift change report on infants born within the last 4 hours. Which
newborn should the nurse assess first?
A) 37 weeks' gestation male, respiratory rate 45
B) 1-day-old female who has not voided
C) 8 pound, 1 ounce female, pulse 150
D) Term male, grunting respirations
Answer: D
Explanation: A) Grunting respirations are an indication of respiratory distress. This infant needs
further assessment and possibly immediate intervention. A normal respiratory rate is 30-60. A
normal pulse is 110-160. Infants should produce one wet diaper within the first 24 hours of life;
however, this is not life-threatening. The nurse should assess the baby with grunting respirations
first.
B) Grunting respirations are an indication of respiratory distress. This infant needs further
assessment and possibly immediate intervention. A normal respiratory rate is 30-60. A normal
pulse is 110-160. Infants should produce one wet diaper within the first 24 hours of life;
first.
C) Grunting respirations are an indication of respiratory distress. This infant needs further
first.
D) Grunting respirations are an indication of respiratory distress. This infant needs further
first.
Page Ref: 2194
Learning Outcome: 2. Identify risk factors and prevention methods associated with the newborn
period.
55
3) A Latina client who has just delivered a newborn son wants to breastfeed but says she would
like to bottle-feed for the first few days. After talking with the client, the nurse learns that the
primary reason for the desire to delay breastfeeding is based on which cultural belief?
A) Colostrum is bad for the baby.
B) Breast milk causes skin rashes.
C) It will cause "evil eye."
D) Thin milk causes diarrhea.
Answer: A
Explanation: A) Some Latino cultures believe breastfeeding should be delayed because
colostrum is bad for the baby. The belief that breast milk causes skin rashes is from the Haitian
culture. The Latino culture does not believe that breastfeeding causes evil eye but rather that
touching the head or the face of the baby causes "evil eye." The belief that thin milk causes
diarrhea is a Haitian cultural belief.
B) Some Latino cultures believe breastfeeding should be delayed because colostrum is bad for
the baby. The belief that breast milk causes skin rashes is from the Haitian culture. The Latino
culture does not believe that breastfeeding causes evil eye but rather that touching the head or the
face of the baby causes "evil eye." The belief that thin milk causes diarrhea is a Haitian cultural
belief.
C) Some Latino cultures believe breastfeeding should be delayed because colostrum is bad for
belief.
D) Some Latino cultures believe breastfeeding should be delayed because colostrum is bad for
belief.
Page Ref: 2245
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care for
newborns and their families.
56
4) The nurse is caring for a newborn male client recovering from a circumcision. Which nursing
diagnosis would be appropriate for the client after the procedure?
A) Risk for Injury
B) Risk for Infection
C) Risk for Imbalanced Nutrition
D) Risk for Ineffective Breathing Pattern
Answer: B
Explanation: A) The client is at increased risk for infection because of the circumcision. Risk for
Injury would be appropriate if the client were having difficulty metabolizing bilirubin. Risk for
Ineffective Breathing Pattern would be appropriate if the client were demonstrating signs of
ineffective breathing. Risk for Imbalanced Nutrition would be appropriate if the client were
demonstrating signs of ineffective feeding behaviors.
B) The client is at increased risk for infection because of the circumcision. Risk for Injury would
be appropriate if the client were having difficulty metabolizing bilirubin. Risk for Ineffective
Breathing Pattern would be appropriate if the client were demonstrating signs of ineffective
breathing. Risk for Imbalanced Nutrition would be appropriate if the client were demonstrating
signs of ineffective feeding behaviors.
C) The client is at increased risk for infection because of the circumcision. Risk for Injury would
D) The client is at increased risk for infection because of the circumcision. Risk for Injury would
Page Ref: 2245
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for a healthy newborn.
57
5) A nurse is caring for the 1-hour-old infant of a diabetic mother. What should be included in
the plan of care for this newborn?
A) Assess blood glucose hourly and then every 4 hours.
B) Evaluate blood glucose levels at birth and at 6-hour intervals.
C) Assess for hyperthyroidism.
D) Assess the newborn's temperature hourly.
E) Use formula for all feedings, avoiding 5% dextrose.
Answer: A, E
Explanation: A) Newborns of diabetic mothers can require frequent feedings to maintain normal
levels of blood glucose. Formula feedings contain protein and will maintain blood sugar better
than glucose water alone. Alteration in temperature is not associated with newborns of diabetic
mothers. The onset of hypoglycemia occurs at 1-3 hours after birth and can continue for several
days. Blood glucose levels should be checked hourly during the first 4 hours and then at 4-hour
intervals until stable normal levels are attained. Hyperthyroidism is not associated with newborns
of diabetic mothers.
B) Newborns of diabetic mothers can require frequent feedings to maintain normal levels of
blood glucose. Formula feedings contain protein and will maintain blood sugar better than
glucose water alone. Alteration in temperature is not associated with newborns of diabetic
C) Newborns of diabetic mothers can require frequent feedings to maintain normal levels of
D) Newborns of diabetic mothers can require frequent feedings to maintain normal levels of
58
E) Newborns of diabetic mothers can require frequent feedings to maintain normal levels of
Page Ref: 2197
Learning Outcome: 6. Plan evidence-based care for a healthy newborn and his or her family.
59
6) The nurse is instructing a new mother on how to care for the newborn's circumcision site.
Which statement or statements indicate that the nurse's education session was effective?
A) "I should not use petroleum jelly on the penis."
B) "Every time I change the diaper I am to wash the area with warm water."
C) "I should report any pus drainage or change in diaper wetness to the physician."
D) "Swelling is expected."
E) "I am to use soap and water to remove yellow tissue on the penis."
Answer: B, C
Explanation: A) The nurse should instruct the mother to wash the area with warm water after
every diaper change, to use petroleum jelly to protect the penis and prevent bleeding, and to
report any pus drainage or change in urine output to the physician. Yellow tissue on the penis is
granulation tissue, which is evidence of healing and should not be washed off with soap and
water. Swelling is not expected after a circumcision and should be reported to the physician.
B) The nurse should instruct the mother to wash the area with warm water after every diaper
change, to use petroleum jelly to protect the penis and prevent bleeding, and to report any pus
drainage or change in urine output to the physician. Yellow tissue on the penis is granulation
tissue, which is evidence of healing and should not be washed off with soap and water. Swelling
is not expected after a circumcision and should be reported to the physician.
C) The nurse should instruct the mother to wash the area with warm water after every diaper
D) The nurse should instruct the mother to wash the area with warm water after every diaper
E) The nurse should instruct the mother to wash the area with warm water after every diaper
Page Ref: 2241
Learning Outcome: 7. Evaluate expected outcomes for the newborn.
60
7) When administering an intramuscular dose of vitamin K (AquaMEPHYTON) to a newborn,
the nurse will do which of the following?
A) Use a 23-gauge 1/2-inch needle.
B) Clean the skin with an alcohol swab.
C) Prepare 5 mg of the medication for injection.
D) Use the middle third of the vastus lateralis muscle.
E) Wash the skin with soap and water.
Answer: B, D
Explanation: A) A single dose of vitamin K (AquaMEPHYTON) is administered to newborns
within 1 hour of birth. The nurse should use the middle third of the vastus lateralis muscle, clean
the skin with an alcohol swab, and use a 27-gauge 1/2-inch needle. The skin is not to be washed
with soap and water before the injection. The medication dosage is between 0.5 and 1.0 mg.
B) A single dose of vitamin K (AquaMEPHYTON) is administered to newborns within 1 hour of
birth. The nurse should use the middle third of the vastus lateralis muscle, clean the skin with an
alcohol swab, and use a 27-gauge 1/2-inch needle. The skin is not to be washed with soap and
water before the injection. The medication dosage is between 0.5 and 1.0 mg.
C) A single dose of vitamin K (AquaMEPHYTON) is administered to newborns within 1 hour of
D) A single dose of vitamin K (AquaMEPHYTON) is administered to newborns within 1 hour of
E) A single dose of vitamin K (AquaMEPHYTON) is administered to newborns within 1 hour of
Page Ref: 2198
care of a newborn and his or her family.
61
8) The nurse is providing discharge instructions to a 15-year-old first-time mother and her baby.
What should be included in these instructions?
A) "Your baby's stools will change to a golden yellow color when your milk comes in."
B) "Call your pediatrician if the baby's temperature is 97°F."
C) "Your infant should wet a diaper at least six times per day."
D) "You can wipe away any eye drainage that might form."
Answer: C
Explanation: A) A minimum of six wet diapers per day indicates adequate fluid intake for the
infant. A temperature of 97°F is considered normal. Stool color turns a golden brown when
lactation is established. Eye drainage is abnormal and should be reported to the baby's provider.
B) A minimum of six wet diapers per day indicates adequate fluid intake for the infant. A
temperature of 97°F is considered normal. Stool color turns a golden brown when lactation is
established. Eye drainage is abnormal and should be reported to the baby's provider.
C) A minimum of six wet diapers per day indicates adequate fluid intake for the infant. A
D) A minimum of six wet diapers per day indicates adequate fluid intake for the infant. A
Page Ref: 2201
Learning Outcome: 6. Plan evidence-based care for a healthy newborn and his or her family.
62
9) What information would a nurse use as a primary consideration in distinguishing physiologic
versus pathologic jaundice in a newborn?
A) Signs of physiologic jaundice in a newborn appear after the first 24 hours postnatally,
whereas those of pathologic jaundice manifest at birth or within the first 24 hours of life.
B) Signs of physiologic jaundice in a newborn appear at birth or before the first 24 hours
postnatally.
C) The skin of the newborn with physiologic jaundice tends to be yellow; in pathologic jaundice
the newborn's skin tends to be very pale.
D) Pathologic jaundice is not masked by artificial lighting, whereas physiologic jaundice may be
difficult to discern in artificial lighting.
Answer: A
Explanation: A) Signs of physiologic jaundice in a newborn appear after the first 24 hours
postnatally, whereas those of pathologic jaundice manifest at birth or within the first 24 hours of
life. Both types of jaundice are characterized by yellow discoloration of the skin that results from
increased levels of unconjugated (indirect) bilirubin, a normal product of red blood cell (RBC)
breakdown, and the newborn's temporary inability to eliminate the accumulated bilirubin from
the body. Artificial lighting may hinder the detection of either physiologic or pathologic newborn
jaundice.
B) Signs of physiologic jaundice in a newborn appear after the first 24 hours postnatally,
whereas those of pathologic jaundice manifest at birth or within the first 24 hours of life. Both
types of jaundice are characterized by yellow discoloration of the skin that results from increased
levels of unconjugated (indirect) bilirubin, a normal product of red blood cell (RBC) breakdown,
and the newborn's temporary inability to eliminate the accumulated bilirubin from the body.
Artificial lighting may hinder the detection of either physiologic or pathologic newborn jaundice.
C) Signs of physiologic jaundice in a newborn appear after the first 24 hours postnatally,
D) Signs of physiologic jaundice in a newborn appear after the first 24 hours postnatally,
Page Ref: 2223
Learning Outcome: 1. Describe the normal physiologic adaptations of the newborn to
extrauterine life.
63
10) The nurse conducting a 5-minute Apgar assessment on a newborn female assigns the
following ratings: Heart rate < 100 beats per minute (1 point); slow, irregular respirations (1
point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2
points); and a pink body with blue extremities (1 point). What is the most appropriate set of
actions for the nurse to take?
A) Have the nursery aide initiate measures to increase the baby's heart rate and respirations by
gently stimulating the baby, with the nurse then repeating the Apgar in 10 minutes.
B) Swaddle the infant to keep her warm and calm to avoid having the newborn expend energy
due to being distressed, fussy, or crying.
C) Swaddle the newborn, place the baby in the mother's arms, and ask the mother to continue to
observe the infant's respirations for change.
D) Provide suctioning and oxygen as needed, repeat the scoring every 5 minutes for up to 20
minutes, and prepare for resuscitation if needed.
Answer: D
Explanation: A) With a 5-minute Apgar of 6, this newborn is at increased risk for complications
compared to those with Apgar scores in the range of 7 to 10. This infant will likely require
additional suctioning and oxygen, and will need to be carefully monitored to document
improvement in and not worsening of her status. Toward this end, the Apgar assessment should
be repeated by the nurse every 5 minutes for up to 20 minutes. Placing the infant in the mother's
arms and asking the mother to observe the baby's respirations for changes and asking the aide to
gently stimulate the infant to increase the heart rate and respirations are not appropriate care
measures. In addition, although it is important to keep the infant warm and calm to avoid placing
the baby under additional stress, keeping the infant unclothed and under a warmer in the
immediate period following birth allows for unencumbered observation of respirations, muscle
tone, and color so that accurate comparisons over time can be made.
B) With a 5-minute Apgar of 6, this newborn is at increased risk for complications compared to
those with Apgar scores in the range of 7 to 10. This infant will likely require additional
suctioning and oxygen, and will need to be carefully monitored to document improvement in and
not worsening of her status. Toward this end, the Apgar assessment should be repeated by the
nurse every 5 minutes for up to 20 minutes. Placing the infant in the mother's arms and asking
the mother to observe the baby's respirations for changes and asking the aide to gently stimulate
the infant to increase the heart rate and respirations are not appropriate care measures. In
addition, although it is important to keep the infant warm and calm to avoid placing the baby
under additional stress, keeping the infant unclothed and under a warmer in the immediate period
following birth allows for unencumbered observation of respirations, muscle tone, and color so
that accurate comparisons over time can be made.
C) With a 5-minute Apgar of 6, this newborn is at increased risk for complications compared to
64
D) With a 5-minute Apgar of 6, this newborn is at increased risk for complications compared to
Page Ref: 2210
newborns and their families.
65
11) An infant born after 37 weeks' gestation weighs 1,750 g (3 pounds, 10 ounces). The head
circumference and length are at the 25th percentile. What statement would the nurse use to
describe these assessment findings?
A) Preterm appropriate for gestational age, asymmetrical intrauterine growth restriction
B) Preterm appropriate for gestational age, symmetrical intrauterine growth restriction
C) Preterm small for gestational age, asymmetrical intrauterine growth restriction
D) Term small for gestational age, symmetrical intrauterine growth restriction
Answer: C
Explanation: A) The infant is preterm at 37 weeks. Because the weight is below the 10th
percentile, the infant is not appropriate for gestational age but is considered small for gestational
age. Head circumference and length between the 10th and 90th percentiles indicate asymmetrical
intrauterine growth restriction. Symmetrical intrauterine growth restriction would have head
circumference below the 10th percentile.
B) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant
is not appropriate for gestational age but is considered small for gestational age. Head
circumference and length between the 10th and 90th percentiles indicate asymmetrical
C) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant
D) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant
Page Ref: 2205
Learning Outcome: 1. Describe the physiologic differences in the premature infant in
comparison to the term infant.
66
Exemplar 33.5 Prematurity
1) When caring for a preterm infant, the nurse will add interventions to address thermoregulation
because the infant:
A) Will have flexed extremities.
B) Will lose heat faster than a full-term infant.
C) Has hyperconstriction of the blood vessels.
D) Has less subcutaneous fat.
E) Has thicker skin.
Answer: B, D
Explanation: A) Interventions to address thermoregulation of a preterm infant are important
because the preterm infant has a higher ratio of body surface to body weight, causing the infant
to lose heat faster than a full-term infant. The preterm infant also has less subcutaneous fat and
thinner skin. Flexed extremities will reduce the amount of heat lost. The preterm infant will have
poor vasoconstriction tone and not hyperconstriction of blood vessels.
B) Interventions to address thermoregulation of a preterm infant are important because the
preterm infant has a higher ratio of body surface to body weight, causing the infant to lose heat
faster than a full-term infant. The preterm infant also has less subcutaneous fat and thinner skin.
Flexed extremities will reduce the amount of heat lost. The preterm infant will have poor
vasoconstriction tone and not hyperconstriction of blood vessels.
C) Interventions to address thermoregulation of a preterm infant are important because the
D) Interventions to address thermoregulation of a preterm infant are important because the
E) Interventions to address thermoregulation of a preterm infant are important because the
Page Ref: 2250
Learning Outcome: 2. Identify risk factors associated with prematurity.
67
2) After giving birth to a preterm infant who is being cared for in the neonatal intensive care unit,
an adolescent client says, "My baby doesn't seem real because she's in the hospital and I'm at
home." What can the nurse do to promote parent-infant attachment?
A) Limit visits to the intensive care unit so as not to disrupt care of the baby needs.
B) Explain that once the baby is discharged to home, she will have evidence that the baby is real.
C) Have the mother visit when the baby is asleep or resting.
D) Provide a picture of the infant including a footprint and current weight and length.
Answer: D
Explanation: A) Nurses need to take measures to promote positive parental feelings toward the
preterm infant. One way to do this would be to provide the mother with a picture of the infant
including a footprint and current weight and length. This promotes bonding. The mother needs to
begin bonding with the infant now, not wait until the baby is discharged to home. Visits to the
intensive care unit should be encouraged and supported. The mother should try to visit with the
infant when the baby is awake to encourage interaction.
B) Nurses need to take measures to promote positive parental feelings toward the preterm infant.
One way to do this would be to provide the mother with a picture of the infant including a
footprint and current weight and length. This promotes bonding. The mother needs to begin
bonding with the infant now, not wait until the baby is discharged to home. Visits to the
C) Nurses need to take measures to promote positive parental feelings toward the preterm infant.
D) Nurses need to take measures to promote positive parental feelings toward the preterm infant.
Page Ref: 2258
premature infants and their families.
68
3) The mother of a preterm infant tells the nurse that she was not looking forward to having a
baby and now that the baby is sick, she feels worse. Which nursing diagnosis is the most
appropriate for this situation at this time?
A) Parental Role Conflict
B) Impaired Parenting
C) Dysfunctional Family Processes
D) Ineffective Family Coping
Answer: D
Explanation: A) Ineffective Family Coping is the nursing diagnosis most appropriate for this
situation at this time because the mother is expressing anger and guilt at having given birth to a
premature baby. Parental role conflict is seen if the role of parent is in conflict with other
expectations. Impaired parenting is seen if the mother is unable to fulfill the role of mother to the
baby. Dysfunctional family process is seen if the addition of a baby leads to the family's inability
to function as a family.
B) Ineffective Family Coping is the nursing diagnosis most appropriate for this situation at this
time because the mother is expressing anger and guilt at having given birth to a premature baby.
Parental role conflict is seen if the role of parent is in conflict with other expectations. Impaired
parenting is seen if the mother is unable to fulfill the role of mother to the baby. Dysfunctional
family process is seen if the addition of a baby leads to the family's inability to function as a
family.
C) Ineffective Family Coping is the nursing diagnosis most appropriate for this situation at this
family.
D) Ineffective Family Coping is the nursing diagnosis most appropriate for this situation at this
family.
Page Ref: 2255
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for the premature infant.
69
4) When planning the care for a preterm infant with ineffective thermoregulation, the nurse
should include which intervention?
A) Keep the baby's head uncovered.
B) Rinse hands with cold water before providing care to the infant.
C) Place incubator near a window or source of fresh air.
D) Allow skin-to-skin contact with the mother to maintain warmth.
Answer: D
Explanation: A) The nurse needs to plan for a neutral thermal environment to minimize oxygen
consumption, prevent cold stress, and facilitate growth of the preterm infant. To do this, the
nurse should plan for the infant to have skin-to-skin contact with the mother to maintain warmth.
The hands should be rinsed with warm water before providing care to the infant. The baby's head
should be covered because the head is 25% of the baby's size and is prone to evaporative heat
loss. Incubators should be moved away from drafts or open windows to reduce radiative and
conductive heat loss.
B) The nurse needs to plan for a neutral thermal environment to minimize oxygen consumption,
prevent cold stress, and facilitate growth of the preterm infant. To do this, the nurse should plan
for the infant to have skin-to-skin contact with the mother to maintain warmth. The hands should
be rinsed with warm water before providing care to the infant. The baby's head should be
covered because the head is 25% of the baby's size and is prone to evaporative heat loss.
Incubators should be moved away from drafts or open windows to reduce radiative and
C) The nurse needs to plan for a neutral thermal environment to minimize oxygen consumption,
D) The nurse needs to plan for a neutral thermal environment to minimize oxygen consumption,
Page Ref: 2256
Learning Outcome: 6. Plan evidence-based care for a premature infant and his or her family in
70
5) The nurse is instructing the parents who delivered their first child at 34 weeks. Which
statement or statements indicate that additional teaching is needed?
A) "Tube feedings will be required because his stomach is small."
B) "Breathing might be harder for our baby because he is early."
C) "Our baby will be in an isolette to keep him warm."
D) "The growth of our baby will be slower than if he were term."
E) "Because he came early, he will not produce urine for two days."
Answer: A, E
Explanation: A) Preterm infants grow more slowly than do term infants. Although tube feedings
might be required, it would be because preterm babies lack sufficient suck and swallow reflexes
to prevent aspiration. Although preterm babies have diminished kidney function due to
incomplete development of the glomeruli, they will make urine. Preterm infants have little
subcutaneous fat, and have difficulty maintaining their body temperature. An isolette or overhead
warmer is used to keep the baby warm. Surfactant production might not be complete at 34
weeks, which leads to respiratory distress syndrome. In addition, respiratory effort is increased
when the ductus arteriosus remains patent, which is common in preterm infants.
B) Preterm infants grow more slowly than do term infants. Although tube feedings might be
required, it would be because preterm babies lack sufficient suck and swallow reflexes to prevent
aspiration. Although preterm babies have diminished kidney function due to incomplete
development of the glomeruli, they will make urine. Preterm infants have little subcutaneous fat,
and have difficulty maintaining their body temperature. An isolette or overhead warmer is used
to keep the baby warm. Surfactant production might not be complete at 34 weeks, which leads to
respiratory distress syndrome. In addition, respiratory effort is increased when the ductus
arteriosus remains patent, which is common in preterm infants.
C) Preterm infants grow more slowly than do term infants. Although tube feedings might be
D) Preterm infants grow more slowly than do term infants. Although tube feedings might be
71
E) Preterm infants grow more slowly than do term infants. Although tube feedings might be
Page Ref: 2250-2251
Learning Outcome: 7. Evaluate expected outcomes for a premature infant.
72
6) The nurse is monitoring the intake and output for a male preterm infant. What will the nurse
do to correctly assess the infant's output?
A) Document "unable to obtain" on the graphic sheet.
B) Apply an external condom catheter.
C) Insert an indwelling urinary catheter.
D) Weigh diapers using the estimate that 1 ml = 1 gram of weight.
Answer: D
Explanation: A) Weigh change is one of the most sensitive indicators of fluid balance. Weighing
diapers is the intervention used to accurately measure the output of an infant. The estimate is that
1 gm of body weight is equal to 1 ml of fluid. The nurse should not insert an indwelling urinary
catheter or apply an external condom catheter on the infant. Documenting "unable to obtain" on
the graphic sheet does not support the need to accurately measure the infant's output.
B) Weigh change is one of the most sensitive indicators of fluid balance. Weighing diapers is the
intervention used to accurately measure the output of an infant. The estimate is that 1 gm of body
weight is equal to 1 ml of fluid. The nurse should not insert an indwelling urinary catheter or
apply an external condom catheter on the infant. Documenting "unable to obtain" on the graphic
sheet does not support the need to accurately measure the infant's output.
C) Weigh change is one of the most sensitive indicators of fluid balance. Weighing diapers is the
D) Weigh change is one of the most sensitive indicators of fluid balance. Weighing diapers is the
Page Ref: 2257
Learning Outcome: 5. Summarize therapies used by the interdisciplinary team in the
collaborative care of a premature infant.
73
7) The nurse is preparing to provide an enteral feeding to a preterm infant. What should the nurse
do prior to administering this feeding?
A) Weigh the current diaper.
B) Measure abdominal girth.
C) Weigh the baby.
D) Measure pulse oximetry.
Answer: B
Explanation: A) Before each feeding, the nurse should measure the abdominal girth to determine
abdominal distention, which is seen in necrotizing enterocolitis or paralytic ileus. Weighing the
baby and weighing diapers are interventions to assess for fluid volume status. Measuring pulse
oximetry is an intervention for assessing oxygenation.
B) Before each feeding, the nurse should measure the abdominal girth to determine abdominal
distention, which is seen in necrotizing enterocolitis or paralytic ileus. Weighing the baby and
weighing diapers are interventions to assess for fluid volume status. Measuring pulse oximetry is
an intervention for assessing oxygenation.
C) Before each feeding, the nurse should measure the abdominal girth to determine abdominal
D) Before each feeding, the nurse should measure the abdominal girth to determine abdominal
Page Ref: 2257
Learning Outcome: 6. Plan evidence-based care for a premature infant and his or her family in
74
8) A nurse has been caring for several weeks for a premature infant with a central line. The baby
had been growing and doing well, but suddenly developed apnea, bradycardia, and metabolic
acidosis. What is the most likely condition causing this change in health status?
A) Hyperbilirubinemia
B) Bacterial sepsis
C) Hypoglycemia
D) Intracranial hemorrhage
Answer: B
Explanation: A) The sudden onset of apnea, bradycardia, and metabolic acidosis in a premature
infant with a central line in place who had previously been growing and doing well is suggestive
of bacterial sepsis rather than hyperbilirubinemia, hypoglycemia, or intracranial hemorrhage.
B) The sudden onset of apnea, bradycardia, and metabolic acidosis in a premature infant with a
central line in place who had previously been growing and doing well is suggestive of bacterial
sepsis rather than hyperbilirubinemia, hypoglycemia, or intracranial hemorrhage.
C) The sudden onset of apnea, bradycardia, and metabolic acidosis in a premature infant with a
D) The sudden onset of apnea, bradycardia, and metabolic acidosis in a premature infant with a
Page Ref: 2229
Learning Outcome: 2. Identify risk factors associated with prematurity.
75
9) The nurse caring for a stabilized preterm infant for the past 3 weeks would expect that the
infant is receiving adequate nutritional intake if the baby consistently gains how many grams a
day?
A) 1,870-1,940 grams (or 70-140 grams over 14 days, or between 5 and 10 g/day since regaining
birth weight)
B) 1,940-2,010 grams (or 140-210 grams over 14 days, or between 10 and 15 g/day since
regaining birth weight)
C) 2,010-2,080 grams (or 210-280 grams over 14 days, or between 15and 20 g/day since
D) 2,080-2,220 grams (or 280-420 grams over 14 days, or between 20 and 30 g/day since
Answer: C, D
Explanation: A) Premature infants, once they recover from the physiologic weight loss that
occurs in newborns following birth (about 5-10% in term infants and 10-15% in preterm infants),
would be expected to gain 20-30 grams/day if their nutritional intake is adequate. Thus, a weight
at 3 weeks of age of between 2,080 grams and 2,220 grams would reflect that the infant had
gained between 280 and 420 grams since regaining his birth weight at the end of his first week of
life. This is equivalent to a consistent weight gain of 20-30 grams/day, which is considered to
reflect adequate nutritional intake. The other values reflect less than 20-30 grams/day of weight
gain, which would suggest that the infant's nutritional needs were not being adequately met.
B) Premature infants, once they recover from the physiologic weight loss that occurs in
newborns following birth (about 5-10% in term infants and 10-15% in preterm infants), would be
expected to gain 20-30 grams/day if their nutritional intake is adequate. Thus, a weight at 3
weeks of age of between 2,080 grams and 2,220 grams would reflect that the infant had gained
between 280 and 420 grams since regaining his birth weight at the end of his first week of life.
This is equivalent to a consistent weight gain of 20-30 grams/day, which is considered to reflect
adequate nutritional intake. The other values reflect less than 20-30 grams/day of weight gain,
which would suggest that the infant's nutritional needs were not being adequately met.
C) Premature infants, once they recover from the physiologic weight loss that occurs in
76
D) Premature infants, once they recover from the physiologic weight loss that occurs in
Page Ref: 2239
premature infants and their families.
77

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