Test bank for maternity nursing an introductory text 11th edition leifer

Link download full: Test Bank for Maternity Nursing An Introductory Text 11th Edition Leifer CLICK HERE MULTIPLE CHOICE The effect of decreased PO2 and increased PCO2 on the newborn infant is to: a Cause the fetal shunts to close b Suppress metabolic processes c Promote chest compression and recoil d Stimulate the brain to begin respirations ANS: D After the umbilical cord is cut, the infant experiences temporary hypoxia and acidosis The changes in arterial oxygen, carbon dioxide, and pH activate the respiratory center in the medulla of the brain to initiate respirations DIF: Cognitive Level: Comprehension REF: 160 | Figure 9-1 OBJ: TOP: Onset of Breathing Process Step: N/A KEY: Nursing MSC: NCLEX: N/A Which statement best explains why newborns who are delivered by cesarean birth are at greater risk for respiratory complications than newborns delivered vaginally? a In most cases, newborns delivered by cesarean are already in fetal distress before birth b A newborn delivered by cesarean does not have the compressions of the birth canal on the chest, which forces fluid from the lungs c Without going through the normal birth process, the newborn delivered by cesarean does not produce surfactant d Newborns delivered by cesarean not develop the temporary hypoxia that normally stimulates respirations ANS: B The chest compressions that occur during a vaginal delivery help express fluid from the lungs A neonate delivered by cesarean birth does not experience this compression and therefore is more likely to have excess fluid in the lungs after delivery DIF: Cognitive Level: Comprehension REF: 161 TOP: Change from Fluid-Filled to Air-Filled Lungs Process Step: N/A OBJ: KEY: Nursing MSC: NCLEX: Physiologic Integrity Normal changes in pulmonary circulation after birth are the result of: a Closure of the pulmonary artery b Opening of the ductus venosus c Low pressure in left heart chambers d Closure of the ductus arteriosus ANS: D After birth, the ductus arteriosus and the ductus venosus close The pulmonary artery does not close If it were to close, the oxygenated blood could not flow to the lungs for oxygenation The pressure in the right side of the heart rises, causing the foramen ovale to close DIF: Cognitive Level: Comprehension REF: 161-162 | Figure 9-2 OBJ: 4-5 TOP: Closing Down Fetal Structures (Shunts) KEY: Nursing Process Step: N/A MSC: NCLEX: Physiologic Integrity A full-term, 3175-g (7-lbs) newborn is admitted to the nursery with a temperature of 35.4° C (96° F) The most likely reason for the low body temperature is: a An excessively cold delivery room b Exhaustion from the birth process c Evaporation from wet skin surface at birth d A decreased metabolic rate ANS: C The most likely explanation for the low temperature is heat loss by evaporation, which occurs when wet surfaces are exposed to air DIF: Cognitive Level: Comprehension REF: 165-166 | Figure 9-4 OBJ: TOP: Factors Contributing to Heat Loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity The nurse recognizes that cold stress in the newborn can lead to: a Acrocyanosis b Hyperglycemia c Acidosis d Atelectasis ANS: C With cold stress, metabolism of brown fat releases fatty acids, which can lead to metabolic acidosis If excess glucose is metabolized in an attempt to maintain body temperature, the infant may become hypoglycemic Acrocyanosis is normal DIF: Cognitive Level: Analysis OBJ: REF: 165 | Figure 9-3 TOP: Thermoregulation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity Which physiologic mechanism does the newborn use to maintain body temperature? a Shivering b Metabolism of brown fat c Production of fatty acids d Decreased glucose metabolism ANS: B The metabolism of brown fat helps the newborn maintain heat around vital organs Newborns cannot shiver like adults The production of fatty acids occurs, but it is not adaptive because it can cause metabolic acidosis Glucose metabolism increases when the newborn is chilled DIF: Cognitive Level: Comprehension REF: 167 TOP: Nonshivering Thermogenesis OBJ: KEY: Nursing Process Step: N/A MSC: NCLEX: Physiologic Integrity The assessment of a newborn at hour of age reveals the following: temperature 36.0° C (96.7° F), heart rate 158 beats/minute, respiratory rate 55 breaths/minute, color pink with acrocyanosis Based on these clinical findings, the nurse should conclude that: a The infant is in respiratory distress b Measures to warm the infant should be taken c The infant is showing signs of cold stress d No nursing interventions are necessary ANS: B The temperature is low, and measures should be instituted to warm the infant to prevent cold stress The heart and respiratory rates are within normal ranges DIF: Cognitive Level: Analysis TOP: Thermoregulation Assessment REF: 167-169 OBJ: KEY: Nursing Process Step: MSC: NCLEX: Physiologic Integrity An infant weighed 3685 g (8 lbs, oz) at birth What would be the maximum amount of weight loss considered normal by the third day of life? a 57 g (2 oz) b 227 g (8 oz) c 368 g (13 oz) d 454 g (16 oz) ANS: C A newborn normally loses as much as 10% of its body weight in the first few days of life For example: lbs, oz = 130 oz (16 oz = lb; so lbs ´ 16 oz = 128 oz + oz = 130 oz) Ten percent of 130 = 13 oz (Or, 10% of 3685 g = 368 g.) DIF: Cognitive Level: Analysis OBJ: REF: 175 | Table 9-4 TOP: Adjustment to Extrauterine Life KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity The nurse is performing an assessment on a 4-hour old newborn Findings include temperature 36.2° C (97.2° F), heart rate 162 beats/minute, respiratory rate 62 breaths/minute with 20-second pauses The nurse’s first action should be to: a Notify the health care provider b Recheck vital signs in hour c Document findings as normal d Return the newborn to the mother’s room for rooming-in ANS: A Although all vital signs are barely abnormal (normal: temperature 36.5° C [97.7° F], heart rate 110-160 beats/minute, respiratory rate 30-60 breaths/minute with 5- to 15-second pauses), the health care provider should be notified because these may be early signs of cold stress or other abnormality The infant should be warmed before rechecking vital signs The infant may be returned to its mother for rooming-in but only after health care provider has been notified DIF: Cognitive Level: Analysis REF: 167-170 OBJ: TOP: Respiratory and Circulatory Function | Changing from Fluid-Filled to Air-Filled Lungs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity 10 A newborn is placed under a radiant warmer The nurse understands that thermoregulation presents a problem for newborns because: a Their normal flexed posture favors heat loss through perspiration b Their renal function is not fully developed, and heat is lost in the urine c They have a thin layer of subcutaneous fat that provides poor insulation d Their small body surface area produces heat loss more rapidly than an adult’s ANS: C Newborns are prone to heat loss because they have a large body surface area in relation to their weight Their skin is thin, blood vessels are close to the surface, and there is little subcutaneous fat for insulation DIF: Cognitive Level: Comprehension REF: 165 TOP: Thermoregulation Implementation OBJ: KEY: Nursing Process Step: MSC: NCLEX: Physiologic Integrity 11 The nurse assessing a newborn recognizes that the most critical physiologic change required of the newborn is: a Initiation and maintenance of respiration “The posterior fontanelle closes in to months; the anterior fontanelle in about 18 months.” d ANS: D There are two fontanelles The posterior fontanelle closes by to months of age, and the anterior fontanelle closes by about 18 months Fontanelles are covered by a tough membrane and can be touched and washed It is normal for the anterior fontanelle to bulge when the infant cries, but it should relax when the infant is calm DIF: Cognitive Level: Application TOP: Fontanelles REF: 170 | 173 OBJ: 10 KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 25 A new father says, “What can the baby see? I have heard they not see very well when they are so little.” What is the most accurate response? a “Babies can best see objects to feet away.” b “Newborns prefer soft colors and images.” c “Babies like human faces and simple patterns.” d “Babies really cannot focus until months of age.” ANS: C Newborn infants can see better than was once thought Although they are near sighted, seeing best at a length of to 10 inches, they can focus, showing a preference for human faces, simple patterns, and contrasting colors DIF: Cognitive Level: Application OBJ: 12 Implementation TOP: Eyes REF: 179 | Figure 9-15 KEY: Nursing Process Step: MSC: NCLEX: Health Promotion and Maintenance 26 The nurse is helping a new mother who is learning to breastfeed her newborn The nurse shows her how to hold the infant and touch the corner of the infant’s mouth, which causes the infant to turn toward the stimulated side The nurse tells the mother that this response is called _ reflex a Moro’s b Tonic neck c Rooting d Sucking ANS: C The rooting reflex helps the newborn locate the source of nourishment DIF: Cognitive Level: Application OBJ: 13 Implementation TOP: Mouth REF: 180 | Table 9-6 KEY: Nursing Process Step: MSC: NCLEX: Health Promotion and Maintenance 27 The nurse is performing an assessment on a 2-hour-old newborn Which finding would warrant a call to the health care provider? a A crepitant-like feeling when assessing the clavicles b Blood glucose of 45 mg/dL when using a Dextrostix c Heart rate of 160 beats/minute after vigorous crying d Passage of a dark green substance from the intestine ANS: A Crepitus in the area of the clavicles may indicate a clavicular fracture Normal blood glucose for a newborn is 45 to 60 mg/dL Heart rate may be 160 beats/minute or higher following vigorous crying Meconium is a dark green substance that normally passes from the intestine of a newborn DIF: Cognitive Level: Analysis OBJ: | 12 Assessment TOP: Neck REF: 176 | Table 9-4 KEY: Nursing Process Step: MSC: NCLEX: Health Promotion and Maintenance 28 The nurse accidentally bumped the newborn’s bassinet The infant responded by extending and abducting the extremities, and the fingers fanned to form a C The infant then flexed both arms in an embracing motion This is an example of which newborn reflex? a Dancing b Moro’s c Rooting d Babinski ANS: B Moro’s reflex is sometimes called the startle reflex because it appears in response to sudden jarring movements or loud noises DIF: Cognitive Level: Comprehension REF: 180 | Table 9-6 OBJ: 13 TOP: Neurologic Assessment Process Step: N/A KEY: Nursing MSC: NCLEX: N/A 29 The reflex that causes the infant’s toes to turn downward when the sole of the foot is stimulated is the _ reflex a Grasp b Plantar c Rooting d Babinski ANS: B Stimulation of the sole of the infant’s foot demonstrates the plantar reflex, in which the toes curl downward DIF: Cognitive Level: Knowledge REF: 180 | Table 9-6 OBJ: 13 TOP: Neurologic Assessment Process Step: N/A KEY: Nursing MSC: NCLEX: N/A 30 As part of the newborn assessment, the nurse inspects the gluteal and popliteal folds of the hips to assess for: a Opisthotonos b Neurologic development c Congenital hip dysplasia d Muscle development ANS: C Asymmetric skin folds warrant further evaluation to confirm or rule out hip dysplasia DIF: Cognitive Level: Application OBJ: 12 Assessment TOP: Back REF: Figure 9-13 | Table 9-4 KEY: Nursing Process Step: MSC: NCLEX: Health Promotion and Maintenance 31 A cephalhematoma is an: a Accumulation of blood between the skin and the periosteum b Edematous molding of the skull resulting from pressure at birth c Accumulation of blood between the periosteum and a bone of the fetal skull d Accumulation of cerebrospinal fluid between the dura mater and a skull bone ANS: C A cephalhematoma is an accumulation of blood between the periosteum and a bone of the infant’s skull, usually as a result of a prolonged or difficult labor It may be unilateral or bilateral and does not cross the suture line Resolution may take up to weeks DIF: Cognitive Level: Comprehension REF: 170 | Figure 9-9 OBJ: 11 TOP: Cephalhematoma Process Step: N/A KEY: Nursing MSC: NCLEX: N/A 32 Before a newborn is discharged, the nurse performs a heel stick to obtain blood for testing The newborn’s mother asks why this is being done The nurse points out that: a Newborn screening tests are done to detect the presence of certain abnormal health conditions before symptoms appear, enabling early intervention b This test will determine whether her infant will need medication to prevent infection c This test will check for anemia, which would necessitate supplemental use of an iron-rich formula d These tests are used to diagnose certain genetic problems so that proper treatment can be started ANS: A The purpose of newborn blood testing is to screen for certain abnormal conditions so that specific diagnostic tests may be done and early interventions begun if necessary These tests are not diagnostic of disease DIF: Cognitive Level: Analysis TOP: Screening REF: 179 | 181 OBJ: 14 KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 33 When a father sees his baby for the first time, he is very concerned because the baby’s head appears elongated The nurse’s best reply would be that the elongation is due to a(n): a Collection of blood under the bones b Collection of fluid in the tissues c Overlapping of bones during birth d Birth defect ANS: C Neonates born head first and vaginally often have an elongated head, called molding, which usually resolves in a few days Molding occurs when the skull bones override each other to allow the head to fit through the birth canal DIF: Cognitive Level: Application TOP: Head REF: 170 OBJ: 11 KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 34 While giving care to a newborn, the nurse observes a depressed anterior fontanelle The nurse reports this to the health care provider immediately because it can be a sign of: a Infection b Dehydration c Shock d Brain hemorrhage ANS: B When the infant is quiet, the anterior fontanelle should be level with the cranial bones A depressed fontanelle is often a late sign of dehydration DIF: Cognitive Level: Comprehension REF: 170 | Skill 9-2 OBJ: 10 Assessment TOP: Fontanelles KEY: Nursing Process Step: MSC: NCLEX: Physiologic Integrity 35 A new mother tells the nurse that her baby must be cold because his hands and feet are blue The nurse explains that this is a common and temporary condition known as: a Harlequin sign b Erythema toxicum c Cutis marmorata d Acrocyanosis ANS: D Cyanosis of the hands and feet in the first week of life is caused by a combination of high hemoglobin and vasomotor instability Parent education regarding this normal finding is helpful Harlequin color change is a deep red color over a longitudinal half of the body, pallor on the other half, caused by an imbalance of autonomic vascular regulatory mechanism Cutis marmorata is a red or blue lacelike pattern on the skin that is a normal vasomotor response to cold Erythema toxicum is a normal, temporary splotchy erythema with firm, yellow-white papules DIF: Cognitive Level: Application OBJ: 12 Implementation TOP: Skin REF: 171 | Table 9-3 KEY: Nursing Process Step: MSC: NCLEX: Health Promotion and Maintenance 36 The nurse recognizes that unequal femoral pulses in a newborn usually indicates: a Ventral-septal defect b Congenital hip dislocation c Patent ductus arteriosus d Coarctation of the aorta ANS: D Femoral pulses should be taken at the same time Diminished or unequal pulses may indicate a heart defect, specifically coarctation of the aorta DIF: Cognitive Level: Analysis TOP: Extremities REF: 168 OBJ: 12 KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 37 The nurse recognizes that the best time to test hearing is when the infant is in which behavioral state of sleep? a Active sleep b Quiet sleep c Quiet alert d Drowsiness ANS: A In the active sleep state, the infant responds easily to the sounds he or she hears In the quiet sleep state, the infant is very difficult to wake If the infant is already awake, it may be more difficult to identify movements and cues as responses to sounds from the hearing test DIF: Cognitive Level: Analysis OBJ: 12 REF: 179 | Table 9-5 TOP: Behavioral States KEY: Nursing Process Step: Planning and Maintenance MSC: NCLEX: Health Promotion MULTIPLE RESPONSE 38 Which factor(s) aid(s) in the initiation of respiration in the neonate immediately following birth? (Select all that apply.) a Touch b Clamping of the umbilical cord c Temperature change d Hunger e Light f Anger ANS: A, B, C, E There are four major categories of stimuli that send messages to the respiratory center of the neonate’s brain to initiate respiration immediately after birth • • • • Sensory: cold, touch, motion, light, sound Chemical: clamping the cord Thermal: temperature change (warm to cool) Mechanical: chest compression and recoil (expansion) A neonate’s lungs must function immediately after birth Sensory stimuli of cold, touch, movement, light, and sound help respirations begin as the fetus emerges from the dark, warm uterus to the external environment Clamping the cord causes temporary hypoxia, producing acidosis, which activates the respiratory center to initiate respirations Temperature change from warm to cool stimulates respiration, but care must be taken to protect the neonate from excessive cold The chest is compressed during passage through the birth canal, then recoils (expands) at the moment of birth DIF: Cognitive Level: Comprehension REF: 160 | Figure 9-1 OBJ: | Process Step: N/A TOP: Onset of Breathing KEY: Nursing MSC: NCLEX: Physiologic Integrity 39 The nurse is performing an assessment of a 12-hour-old newborn Which finding(s) would require further action? a Respirations 40, irregular, shallow b Blood glucose 45 mg/dL c Absence of bowel elimination since birth d No urinary output since birth e Episodic apnea lasting 25 seconds f Jaundice on face and chest