NSG 300 Maternal Newborn 2 ATI – Our lady of Holy Cross College | NSG300 Maternal Newborn 2 ATI

NSG 300 Maternal Newborn 2 ATI – Our lady of Holy Cross College. Maternal Newborn 2 1. A nurse is evaluating the degree of bonding between a mother and her infant who has been hospitalized for a high bilirubin. To collect this data the nurse should a. find out if the pregnancy of this infant was planned. b. provide a cot so that the mother can stay with the infant. c. ask the mother how she feels about her infant. d. observe the mother feeding the infant 2. A nurse caring for a client 14 hr after delivery assesses the following: breasts soft; fundus firm, uterus slightly deviated to the right; lochia moderate rubra; temperature 37.8° C (100° F), pulse 88/min, and respirations 18/min. Which of the following nursing actions should be initiated? a. Notify the provider of the elevated temperature. b. Ask the client to empty her bladder. c. Suggest that the client nurse her infant. d. Massage the client's fundus. 3. A nurse is caring for a newborn in the newborn nursery who weighs 4 lb and 4 oz. Which of the following is a correct conversion pounds to kilograms for this newborn's weight? a. 1.93 kg b. 2 kg c. 9.35 kg d. 9.68 kg 4. In planning postpartum nursing care for a client with cardiac disease, the nurse would question which of the following provider orders? a. Strict intake and output b. High fiber diet c. Force fluids d. Monitor vital signs every 2 hr 5. Which of the following statements made by a client who is nursing should indicate to the nurse that the client has a good understanding of breastfeeding? a. "I must drink milk every day in order to assure good quality breast milk." b. "Fluid intake is very important to adequate breast milk production." c. "I need to add 500 calories to my pregnancy diet to meet both of our nutritional needs." d. "I should avoid nursing my baby more often than every 4 hours." 6. While assessing a 2-day-old newborn, the nurse finds a soft spot on the left side of the newborn's head. Careful inspection reveals a bluish discoloration with edema that does not cross the suture line. What information should the nurse give to the mother when she inquires about the finding? a. "This will resolve within 2 to 6 weeks without treatment." b. "This will resolve on its own within 2 or 3 days." c. "I will ask the doctor to examine your baby’s head carefully this morning." d. "Don’t worry about it; it’s normal." 7. A nurse is caring for a client who has had a cesarean birth and is reporting abdominal distention. Which of the action should the nurse implement? a. Suggest that the client ambulate in the hallway. b. Request a narcotic analgesic be ordered. c. Position the client lying on her right side. d. Encourage the client to drink carbonated drinks. 8. A nurse is caring for a 30 week gestation premature infant. Which of the following in an expected assessment finding? a. Abundant lanugo b. Good flexion c. Heel creases d. Dry, flaky skin 9. A nurse is assessing a newborn immediately after birth and makes these observations: heart rate 136/min, respirations 36/min, vigorous cry, active movement, and acrocyanosis. The nurse should assign an Apgar score of - - - - - - - - - - - - - - - - - 27. A nurse is testing a neonate’s reflexes to assess neurologic maturity. Which reflex is the nurse testing by quickly and gently turning the neonate’s head to one side? a. Startle b. Moro c. Tonic neck d. Babinski 28. A nurse is caring for a 3-day-old infant who is receiving phototherapy for an elevated bilirubin. A nursing action that would put the client is at risk would be to a. swaddle the infant to maintain body temperature. b. keep the eyes and genitalia covered at all times. c. feed the infant every 2 hr. d. allow the parent to hold the infant to promote bonding. 29. What should the nurse include in a postpartal plan of care for a client who does not plan to breastfeed? a. Suggest that the client stand under a hot shower with her breasts exposed. b. Have the client place ice packs on her breasts. c. Have the client wear a loose-fitting, comfortable bra. d. Encourage the client to drink at least eight 8-oz glasses of water per day. 30. A nurse is caring for four neonates in the nursery. Which of the following neonates is at greatest risk for hypoglycemia? a. Neonate of a substance abuser b. Neonate with Rh-incompatibility c. Postmature neonate born at 42 weeks d. Neonate who is large for gestational age (LGA)