Maternity HESI 2, (A Grade)

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn.Which infectious organism will this treatment prevent from harming the infant? a. Herpes b. Staphylococcus c. Gonorrhea d. Syphilis Erythromycin ointment is instilled into the lower conjunctive of each eye within 2 hoursafter birth to prevent ophthalmic neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia (C). The infant may be exposed to these bacteria when passing the birth canal. 2. The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? a. Elicit positive scarf sign on the affected side b. Observe for an asymmetrical Moro (startle) reflex c. Watch for swelling of fingers on the affected side d. Note paralysis of affected extremity and muscles The most common neonatal birth trauma due to vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fracture clavicle should be suspected is an infant has limited use of the affected arm malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal swelling or tenderness, orcries when the arm is moved. 3. The nurse is calculating the estimated date of confinement (EDC) using Nagele's rulefor a client whose last menstrual period started on December 1. Which date is most accurate? a. August 1 b. August 10 c. September 3 d. September 8 Calculation of a client's EDC provides baseline data to monitor fetal gestation. Nagele'srule uses the formula: subtract 3 months and add 7 days to the first day of the last normal menstrual period, so December 1 minus 3 months + 7 days is September 8 (D). 4. A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction ismost important is most important for the nurse to provide this client? a. Elevate lower legs while resting b. Increase caloric intake by 200 to 300 calories per day c. Increase water intake to 8 full glasses per day d. Take prescribed multivitamin and mineral supplements A client who has had a spontaneous abortion or still birth in the last 1.5 years should take multivitamin and mineral supplements (D) and maintain a balanced diet becausethe previous pregnancy may have left her nutritionally depleted. 5. The total bilirubin level of a 36-hour, breastfeeding newborns is 14 mg/dl. Based on thisfinding, which intervention should the nurse implement? a. Feed the newborn sterile water hourly b. Encourage the mother to breastfeed frequently c. Assess the newborn's blood glucose level d. Encourage the mother to breastfeed frequently The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. This infant's bilirubin is beginning to climb, and the infant should be monitored to prevent further complications. Breast milk provides calories and enhances GI motility, which willassist the bowel in eliminating bilirubin (C). 6. Which assessment finding should the nursery nurse report to the pediatric healthcareprovider? a. Blood glucose level of 45 mg/dl b. Blood pressure of 82/45 mmHg c. Non-bulging anterior fontanel d. Central cyanosis when crying An infant who demonstrates central cyanosis when crying (D) is manifesting poor adaptation to extrauterine life which should be reported to the healthcare provider fordetermination of a possible underlying cardiovascular problem. 7. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with hernewborn infant? a. Encourage the mother to provide total care for her infant b. Provide privacy, so the mother can develop a relationship with the infant c. Encourage the father to provide most of the infant's care during hospitalization d. Meet the mother's physical needs and demonstrate warmth toward the infant It is most important to meet the mother's requirement for attention to her needs so that she can begin infant care-taking (D). Nurse theorist Reva Rubin describes the initial postpartum period as the "taking-in phase," which is characterized by maternal relianceon others to satisfy the needs for comfort, rest, nourishment, and closeness to families and the newborn. 8. A client receiving epidural anesthesia begins to experience nausea and becomes paleand clammy. What intervention should the nurse implement first? a. Raise the foot of the bed b. Assess for vaginal bleeding c. Evaluate the fetal heart rate d. Take the client's blood pressure These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (A) will increase venous return and provideblood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrosesolution and ensuring that the silent is in a lateral position are also appropriate interventions. 9. The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and thento white. The client asks, "What if I start having red bleeding after it changes?" What shouldthe nurse instruct the client to do? a. Reduce activity level and notify the healthcare provider b. Go to bed and assume a knee-chest position c. Massage the uterus and go to the emergency room d. Do not worry as this is a normal occurrence Lochia should progress in stages from rubra (red) to serosa (pinkish) to alba (whitish),and not return to red. The return to rubra usually indicates subinvolution of infection.