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Total questions: 79
Worksheet time: 7hrs 35mins
A nurse is caring for a client who is 38 weeks pregnant and has just undergone an amniotomy. Which of the following findings should the nurse recognize as a possible sign of infection?
A. Clear fluid with mild odor
B. Yellow-tinged amniotic fluid with a foul smell
C. Increased fetal movement after the procedure
D. Greenish fluid with a mild odor
A nurse is educating a pregnant client about an amniotomy. Which of the following statements by the client indicates an accurate understanding of the procedure?
A. “An amniotomy is a natural rupture of the membranes that happens during active labor.”
B. “The purpose of an amniotomy is to reduce the need for fetal monitoring.”
C. “An amniotomy uses a sterile instrument to break the amniotic sac to help start or speed up labor.”
D. “Amniotomy is only performed during cesarean delivery.”
A nurse is caring for a client in labor who is experiencing contractions that are frequent, painful, and poorly coordinated, with increased uterine resting tone between contractions. The nurse recognizes these findings are consistent with which of the following?
A. Hypotonic labor
B. Hypertonic labor
C. Precipitous labor
D. Normal labor progression in the active phase
A nurse is caring for a laboring client whose contractions have become weak and infrequent. The client is 6 cm dilated, and her uterine resting tone is soft between contractions. Which of the following conditions is most consistent with these findings?
A. Hypertonic labor
B. Hypotonic labor
C. Normal active phase labor
D. Precipitous labor
A nurse is assessing a newborn at 1 minute after birth using the Apgar scoring system. The newborn has a heart rate of 102 bpm, a strong cry, active movement, a grimace when suctioned, and a pink body with blue extremities. What is the infant’s Apgar score, and what is the appropriate nursing action?
A. Apgar score is 8; continue routine observation and support
B. Apgar score is 6; provide gentle stimulation and assess for respiratory depression
C. Apgar score is 10; no further action needed
D. Apgar score is 3; begin active resuscitation measures immediately
A postpartum nurse is educating a student nurse about the causes of postpartum hemorrhage. Which of the following findings would the nurse identify as a cause of early postpartum hemorrhage?
A. Subinvolution of the uterus
B. Retained placental fragments
C. Uterine atony
D. Endometritis
A nurse is providing discharge teaching to a postpartum client. Which of the following client statements indicates understanding of the causes of late postpartum hemorrhage?
A. "If my uterus is soft and boggy right after birth, I could be hemorrhaging."
B. "I should report any heavy bleeding that starts again a week after going home."
C. "Small vaginal tears during delivery are the most common cause of late hemorrhage."
D. "Bleeding after birth is only considered a problem in the first 24 hours."
A nurse observes a postpartum client experiencing uterine atony with increased vaginal bleeding. What is the nurse’s immediate intervention?
A. Apply fundal massage and encourage infant suckling
B. Prepare the client for surgical intervention
C. Administer intravenous antibiotics
D. Perform a vaginal exam to identify lacerations
A nurse is assessing a term newborn at risk for hypoglycemia. Which of the following signs and symptoms should the nurse expect to observe? (Select all that apply.)
A. Jitteriness, poor muscle tone, and sweating
B. Respiratory difficulty and low temperature
C. Poor suck and high-pitched cry
D. Lethargy and seizures
E. Increased urine output and rash
A nurse assesses a postpartum client 6 hours after delivery. What is the expected location and condition of the uterine fundus at this time?
A. Midline, firm, at or below the level of the umbilicus
B. Deviated to the right side, soft, above the umbilicus
C. Midline, soft, palpable 5 cm above the umbilicus
D. Not palpable because it has fully involuted
Which of the following methods are commonly used to ripen the cervix prior to labor induction? (Select all that apply.)
A. Dinoprostone (Cervidil) vaginal insert
B. Stripping the amniotic membranes
C. Misoprostol administration
D. Administration of oxytocin
E. Transcervical balloon dilator
A pregnant client at 28 weeks gestation is at risk for preterm labor. Which medication is commonly administered to accelerate fetal lung maturity, and how is it given?
A. Betamethasone, two intramuscular injections 24 hours apart
B. Magnesium sulfate, continuous intravenous infusion
C. Oxytocin, intravenous bolus
D. Misoprostol, vaginal insert
After a forceps delivery, which of the following findings should the nurse NOT expect when assessing the newborn’s head?
A. Mild facial reddening
B. Molding of the head
C. Lacerations, abrasions, or bruising
D. Severe skull fractures
After a forceps delivery, what findings should the nurse expect when assessing the newborn’s head?
A. Mild facial reddening and molding of the head
B. Large, open lacerations requiring immediate surgery
C. No changes in head shape or skin condition
D. Severe bruising with skull fractures
Which of the following interventions should a nurse implement during the first 24 hours of caring for a woman with a perineal laceration or episiotomy?
A. Apply cold packs to the perineum for the first 12 hours, then use warm sitz baths
B. Use warm sitz baths during the first 12 hours only
C. Apply heat packs continuously for the first 24 hours
D. Avoid any pain medications for the first 24 hours
What are the potential risks associated with tachysystole during labor?
A. Reduced blood flow to the placenta causing fetal compromise
B. Increased risk of uterine rupture, especially with oxytocin induction or abdominal trauma
C. Enhanced fetal oxygenation due to stronger contractions
D. Decreased maternal pain during labor
Which of the following conditions are indications for labor induction? (Select all that apply.)
A. Gestational hypertension
B. Ruptured membranes without spontaneous labor
C. Abnormal labor progress after 6 cm dilation and 4 to 6 hours of contractions with no cervical change
D. Fetal macrosomia with no complications
E. Infection within the uterus
Which of the following conditions are contraindications for labor induction? (Select all that apply.)
A. Placenta previa
B. Umbilical cord prolapse
C. Gestational hypertension
D. Active herpes infection in the birth canal
E. Previous classic (vertical) cesarean incision
A woman diagnosed with mastitis asks how she can promote healing and comfort while breastfeeding. Which instruction should the nurse include?
A. Apply cold packs only to the affected breast
B. Use moist heat or warm packs to increase blood flow and comfort
C. Avoid breastfeeding the affected breast to prevent pain
D. Wear a tight support bra to limit breast movement
Which of the following instructions should a nurse give to a breastfeeding mother with mastitis to prevent worsening of the infection?
A. Breastfeed only from the unaffected breast
B. Wash hands thoroughly before breastfeeding and expose nipples to air when possible
C. Limit fluid intake to reduce breast swelling
D. Stop breastfeeding and use formula until mastitis resolves
A nurse is testing a newborn’s Moro reflex. Which action should the nurse perform?
A. Stroke the sole of the foot
B. Turn the infant’s head to one side
C. Suddenly lower the infant’s head while holding
D. Place an object in the infant’s hand
When the infant’s head is turned to one side, what is the expected response?
A. Both arms and legs flex
B. Arm and leg on that side extend, opposite side flex
C. Infant grasps object placed in hand
D. Big toe dorsiflexes, other toes fan out
What is the expected response when an object is placed in a newborn’s palm?
A. Infant pulls hand away
B. Infant grasps the object tightly
C. Infant extends arms outward
D. Infant lifts head slightly
How is the Babinski reflex elicited and what is the expected response?
A. Stroking sole of foot; big toe dorsiflexes and other toes fan
B. Sudden loud noise; infant blinks
C. Touching cheek; infant turns head toward touch
D. Placing object in hand; infant grasps
What stimulus causes the newborn to blink?
A. Light touch on cheek
B. Loud noise
C. Stroking sole of foot
D. Object moving toward eye
Which reflex causes a newborn to turn the head toward the source of a noise?
A. Rooting reflex
B. Turning response
C. Moro reflex
D. Sucking reflex
When an object touches the infant’s cheek, what happens?
A. Infant opens mouth and turns head toward the stimulus
B. Infant closes eyes tightly
C. Infant grasps the object
D. Infant extends legs
How is the sucking reflex demonstrated?
A. Infant sucks on finger or nipple placed in mouth
B. Infant lifts head when placed prone
C. Infant blinks when hearing noise
D. Infant curls toes when sole is stroked
How do you elicit the stepping reflex?
A. Stroke sole of foot
B. Hold infant upright over a surface
C. Place object in hand
D. Turn infant’s head to one side
At what age does the Moro reflex typically appear in a full-term newborn?
A. 3 months
B. Birth
C. 5-7 months
D. 4-6 weeks
The tonic neck reflex is present at birth and usually disappears by what age?
A. 3 months
B. 7-12 months
C. 5-7 months
D. 4-5 months
When does the palmar grasp reflex first appear in the newborn?
A. 3 months
B. Birth
C. 6-7 months
D. 4-6 weeks
At what age does the Babinski reflex appear?
A. 3 months
B. Birth
C. 5-7 months
D. 7-12 months
When is the blinking response present in a newborn?
A. Birth
B. 6-7 months
C. 4-6 weeks
D. 2-3 months
At what age does the rooting reflex appear?
A. Birth
B. 3-4 months
C. 7-12 months
D. 4-5 months
When does the sucking reflex first appear in a newborn?
A. 3 months
B. 4-6 weeks
C. Birth
D. 7-12 months
At what age does the stepping reflex typically appear?
A. Birth
B. 3 months
C. 5-7 months
D. 4-5 months
What is the expected amount of weight loss for a full-term newborn during the first 3 to 4 days after birth while still in the hospital?
A. 1% to 3% of birth weight
B. 5% to 10% of birth weight
C. 15% to 20% of birth weight
D. No weight loss is expected
A postpartum patient is showing signs of hypovolemic shock due to hemorrhage. Which of the following interventions should the nurse anticipate? (Select all that apply.)
A. Administer intravenous fluids to maintain circulating volume
B. Perform uterine massage and administer oxytocin
C. Encourage oral fluids to replace lost volume
D. Place a Foley catheter to monitor urine output
E. Provide oxygen therapy and monitor oxygen saturation
A postpartum nurse is assessing a client who has just delivered a baby. The nurse notes excessive vaginal bleeding and a soft, boggy uterus on palpation. Based on this assessment, which condition should the nurse suspect?
A. Endometritis
B. Uterine atony
C. Uterine rupture
D. Retained placenta previa
A nurse is assessing a newborn during the first 24 hours after birth. Which of the following findings should the nurse report to the health care provider?
A. Head circumference is 1.5 cm greater than chest circumference
B. Newborn has voided once in the delivery room
C. No urination has been documented within the first 24 hours
D. Pain assessment findings are documented with appropriate interventions
A nurse is caring for a newborn during the first 24 hours of life. Which of the following findings should the nurse report to the health care provider? (Select all that apply.)
A. Head circumference is more than 2 cm greater than chest circumference
B. The newborn has not voided within the first 24 hours
C. The newborn has fewer than six wet diapers per day after the first day
D. Anuria or unusual urine color is observed
A nurse is educating the parents of a newborn diagnosed with hydrocephalus. Which of the following accurately describes a possible cause of this condition?
A. Inadequate oxygenation during labor
B. Increased absorption of cerebrospinal fluid
C. Obstruction of cerebrospinal fluid flow due to a tumor
D. Underdevelopment of cranial bones
A nurse is assessing a newborn for signs of respiratory distress. Which of the following findings should the nurse recognize as manifestations of respiratory distress?
A. Respiratory rate of 40 breaths per minute and pink skin tone
B. Nasal flaring, intercostal retractions, and respiratory rate of 64 breaths per minute
C. Regular breathing pattern with periods of hiccups and sneezing
D. Quiet breathing with no observable effort and occasional yawning
A nurse is caring for a preterm newborn who has an episode of apnea. Which of the following interventions should the nurse implement first?
A. Begin ventilations using an Ambu bag
B. Suction the nose and mouth
C. Gently rub the infant’s feet, ankles, or back
D. Position the infant in a semi-Fowler’s position
A nurse is assessing a newborn during a routine check. Which of the following vital sign findings is within normal limits for a newborn?
A. Respiratory rate: 24 breaths/min, pulse: 100 bpm, BP: 90/60
B. Respiratory rate: 35 breaths/min, pulse: 150 bpm, BP: 80/46
C. Respiratory rate: 65 breaths/min, pulse: 170 bpm, BP: 78/40
D. Respiratory rate: 30 breaths/min, pulse: 110 bpm, BP: 100/70
A nurse is assessing a postpartum patient for signs of thrombophlebitis. Which of the following findings is associated with a positive Homans’ sign?
A. Calf pain when the foot is passively dorsiflexed
B. Tingling in the foot during active plantar flexion
C. Redness and swelling around the ankle joint
D. Decreased pedal pulses in both feet
What is the primary reason a preterm newborn is at risk for developing respiratory distress?
A. Underdeveloped chest muscles
B. Low oxygen levels during delivery
C. Lung immaturity
D. Small airway diameter
A nurse is assessing a newborn suspected of having neonatal abstinence syndrome (NAS). Which of the following findings are consistent with this condition? (Select all that apply.)
A. Body tremors
B. Hyperirritability
D. Diarrhea
E. Poor feeding
F. Sneezing and yawning
A nurse is caring for a newborn whose mother had gestational diabetes mellitus (GDM). Which of the following complications should the nurse assess for in this infant? (Select all that apply.)
A. Macrosomia
B. Birth injuries
D. Hypoglycemia
E. Hypocalcemia
F. Hyperbilirubinemia
G. Small for gestational age (SGA)
A nurse is teaching new parents how to properly use a bulb syringe to clear their newborn’s airway. Which of the following instructions should the nurse include? (Select all that apply.)
A. Compress the bulb before inserting it into the infant’s mouth or nose
D. Insert the syringe into the side of the mouth to avoid triggering the gag reflex
E. Release the bulb to create suction and listen for mucus being removed
F. Suction one nostril at a time, compressing the bulb before insertion and releasing to suction
G. Demonstrate the technique to parents and explain how to clean and store the syringe
A nurse is teaching a postpartum woman about the return of her menstrual cycle. Which of the following statements by the woman indicates understanding of the teaching?
A. "If I’m not breastfeeding, my period will return in about 8 weeks."
B. "If I’m breastfeeding without using formula, my period may return around 8 weeks."
C. "If I’m formula-feeding, I don’t need to worry about birth control until after my period returns."
D. "Ovulation won’t occur until after my first period postpartum."
A nurse is preparing to initiate gavage feeding for a preterm newborn. Which of the following actions should the nurse take before starting the feeding?
A. Elevate the head of the bed and check for stool output after feeding
B. Warm the formula and flush the feeding tube with water
C. Observe for bowel sounds and check for passage of meconium stools
D. Administer the feeding and then aspirate gastric residuals
A nurse is assessing a newborn baby girl and observes a small amount of blood-tinged mucus from the vaginal area. Which of the following statements accurately explains this finding?
A. "This is a sign of infection and should be reported immediately."
B. "This discharge is a normal finding called pseudo-menstruation caused by maternal hormone withdrawal."
C. "This indicates internal injury during delivery and requires urgent intervention."
D. "This is an abnormal sign of a bleeding disorder and needs further testing."
nurse is caring for a newborn undergoing a minor painful procedure. Which of the following are appropriate noninvasive interventions for pain control in the newborn? (Select all that apply.)
A. Swaddling with the infant’s hand near the mouth
B. Providing oral sucrose before the procedure
C. Cuddling and rocking the infant after the procedure
D. Holding the infant in a face-down 45° angle while gently moving the hips
F. Creating a quiet environment during and after the procedure
G. Offering a pacifier for nonnutritive sucking
A postpartum nurse is assessing a woman who is experiencing bleeding after delivery. Which of the following findings suggests a laceration in the reproductive tract?
A. Dark red bleeding with clots and a boggy uterus
B. Bright red bleeding in a continuous trickle with a firm uterus
C. Lochia that increases in amount and changes from red to brown
D. Severe abdominal cramping and decreased urinary output
What does the term macrosomia mean in relation to newborns?
A. An infant with low birth weight due to prematurity
B. An infant who is large for gestational age, often born to diabetic mothers
C. An infant with poor muscle tone at birth
D. An infant with congenital anomalies affecting growth
A nurse is assessing a postpartum woman’s perineal healing using the REEDA scale. What does each letter in REEDA stand for, and what findings should the nurse expect for normal healing?
A. Redness—painful redness indicates normal inflammation;
Ecchymosis—large bruises are common;
Edema—severe edema is normal;
Discharge—small amounts of discharge are expected;
Approximation—the suture line should be separated
B. Redness—redness without excessive tenderness is normal, but pain suggests infection;
Edema—mild edema is common, severe edema interferes with healing;
Ecchymosis—a few small superficial bruises are common, large bruises interfere with healing;
Discharge—no discharge should be present from the suture line;
Approximation—the suture line should be intact without separation
C. Redness—absence of redness indicates infection;
Edema—edema is never normal;
Ecchymosis—bruising is always a sign of infection;
Discharge—discharge is normal and expected;
Approximation—the suture line should be loose to allow drainage
D. Redness—painful redness indicates no problem;
Edema—severe edema supports healing;
Ecchymosis—large bruises are helpful;
Discharge—some pus discharge is expected;
Approximation—the suture line may be partially open
A nurse is caring for a newborn with hypothermia. What are potential complications the nurse should monitor for? (Select all that apply.)
A. Hypoglycemia due to increased glucose use for heat production
B. Respiratory distress from increased oxygen consumption
C. Hyperbilirubinemia from liver immaturity
D. Seizures caused by low calcium levels
E. Dehydration from increased insensible water loss
What is spina bifida?
A. A genetic disorder causing progressive muscle weakness
B. A central nervous system disorder involving malformation of the spinal cord
C. A condition where the brain fails to develop properly
D. An infection of the spinal cord and surrounding tissues
A nurse is teaching a new mother about mood changes that can occur after childbirth. Which of the following statements correctly describe the differences between baby blues, postpartum depression, and postpartum psychosis?
A. Baby blues affect about 70% of women, usually start around day 5 postpartum, and resolve by day 10 with the mother generally still enjoying life.
B. Postpartum depression typically appears within 2 to 4 weeks after delivery and includes symptoms such as intense feelings of inadequacy, disturbed sleep, and loss of interest in others.
C. Postpartum psychosis involves a severe impairment of reality perception and may include delusions, such as believing the infant is dead.
D. Baby blues involve serious psychiatric disorders such as bipolar disorder and major depression.
E. Postpartum psychosis is more common than postpartum depression and baby blues.
A nurse is educating a postpartum woman about mood changes after childbirth. Which of the following statements accurately describe baby blues, postpartum depression, and postpartum psychosis?
A. Baby blues affect about 70% of women, usually start around day 5 postpartum, and resolve by day 10; women generally still find pleasure in life despite mood swings.
B. Postpartum depression usually appears within 2 to 4 weeks after delivery and includes symptoms like lack of enjoyment, feelings of guilt, disturbed sleep, and difficulty concentrating.
C. Postpartum psychosis involves a severe break with reality, may include hallucinations or delusions such as believing the infant is dead, and is often associated with bipolar disorder or major depression.
D. Postpartum psychosis is more common than baby blues and postpartum depression.
E. Baby blues are a serious psychiatric condition requiring hospitalization.
Why do breastfed newborns typically feed more frequently than formula-fed newborns?
A. Breastfed babies have larger stomach capacities than formula-fed babies.
B. Breastmilk is digested more quickly, requiring more frequent feedings.
C. Formula is easier to digest, so formula-fed babies need to feed more often.
D. Breastfed babies sleep longer between feedings, so feedings are less frequent.
A nurse is performing a BUBBLEHE assessment on a postpartum patient. Which of the following components are included in this assessment? (Select all that apply.)
A. Breast
F. Episiotomy
B. Uterus
G. Homans’ sign
C. Bowel
H. Emotional status
D. Bladder
E. Lochia
A nurse is caring for an Rh-negative pregnant woman. In which of the following situations is Rho(D) immune globulin (RhoGAM) appropriately administered? (Select all that apply.)
A. At 28 weeks of gestation during a routine prenatal visit
B. Within 72 hours after delivering an Rh-positive infant
C. After an amniocentesis procedure
D. After the mother receives a Rubella vaccine postpartum
E. Following a spontaneous abortion in the first trimester
F. When an Rh-negative woman has vaginal bleeding during pregnancy
A pregnant woman tests positive for Group B Streptococcus (GBS) in her urine culture during the second trimester. What is the appropriate treatment plan? (Select all that apply.)
A. Administer antibiotics during pregnancy for a GBS-positive urine culture
B. Monitor for symptoms and treat only if the woman develops a fever
C. Administer antibiotics to the newborn after birth
D. No treatment is needed unless GBS is found in vaginal swabs at 36 weeks
E. Plan for cesarean delivery to prevent GBS transmission
A nurse is preparing to administer routine medications to a healthy term newborn. Which of the following medications are commonly given and for what purpose? (Select all that apply.)
A. Vitamin K — to help prevent bleeding by supporting clotting factor production
B. Hepatitis B vaccine — to prevent transmission of hepatitis B virus
C. Erythromycin eye ointment — to prevent eye infections such as gonococcal conjunctivitis
D. Ibuprofen — to manage pain related to newborn procedures
E. Ampicillin — to prevent Group B Streptococcus in all newborns
A nurse is teaching a group of students about the different ways a newborn can lose heat and how to prevent them. Which of the following pairs correctly match the type of heat loss with its source and appropriate nursing intervention? (Select all that apply.)
A. Evaporation — Heat is lost when wet skin from amniotic fluid evaporates; dry the newborn quickly and cover the head.
B. Conduction — Heat is lost to a cold surface such as a cold scale or stethoscope; prewarm the equipment and use warm blankets.
C. Convection — Heat is lost through cool surrounding air or drafts; keep crib away from windows and vents.
D. Radiation — Heat is lost through direct contact with cold objects; place infant skin-to-skin with mother.
E. Radiation — Heat is lost to nearby cold surfaces like walls or windows; wrap the newborn and keep crib away from cold walls.
A newborn is diagnosed with spina bifida at birth. Which of the following nursing interventions and assessments are appropriate in the care of this newborn? (Select all that apply.)
A. Place the newborn in a prone position to prevent pressure on the sac.
G. Educate parents and involve them in ongoing care and habilitation planning.
B. Apply moist, sterile saline dressings to the sac to prevent drying.
I. Observe the sac for size, leakage, and signs of infection.
C. Measure head circumference and observe fontanelles to assess for hydrocephalus.
E. Monitor and document movement and possible deformities of extremities.
F. Provide meticulous skin care, especially if the infant is incontinent.
A newborn exhibits signs of respiratory depression shortly after birth. The mother received meperidine during labor. Which of the following medications should the nurse anticipate administering to reverse the effects of the opioid?
A. Flumazenil
B. Naloxone (Narcan)
C. Epinephrine
D. Oxygen via nasal cannula
A nurse is educating a group of nursing students about labor management. Which of the following statements correctly differentiate induction from augmentation of labor?
A. Induction of labor is used only after contractions have started naturally.
B. Augmentation of labor involves initiating labor before any contractions begin.
C. Induction of labor is the intentional initiation of labor before it begins naturally.
D. Augmentation of labor is used to stimulate contractions that have already started on their own.
E. Both induction and augmentation are only used in post-term pregnancies.
A nurse is caring for a newborn receiving phototherapy for jaundice. What is the primary purpose of this treatment?
A. To increase the newborn’s red blood cell production
B. To decrease the risk of hypoglycemia
C. To reduce serum bilirubin levels and prevent complications
D. To improve oxygenation and prevent respiratory distress
A nurse is teaching a new mother about the benefits of breastfeeding for her newborn. Which of the following statements accurately describe the benefits of breastfeeding? (Select all that apply.)
A. Breastfeeding provides natural immunity through the transfer of maternal antibodies.
B. Colostrum is low in antibodies but high in calories.
. G. Breastmilk may lack some essential nutrients and should be supplemented with formula early on.
C. Breastfeeding supports brain development in the newborn.
F. Breastmilk automatically adjusts to meet the changing needs of the newborn.
D. Suckling at the breast promotes proper mouth development.
E. Breastmilk is easily digested by the newborn’s immature digestive system.
A nurse is reviewing risk factors for preterm labor with a group of student nurses. Which of the following are known risk factors associated with preterm birth? (Select all that apply.)
A. Multiple gestation
B. Gestational hypertension
C. Placenta previa
D. Maternal malnutrition or chronic illness
E. Smoking or substance abuse
F. Low socioeconomic status (poverty)
G. Full-term pregnancy
H. Premature rupture of membranes (PROM)
I. Type 1 diabetes mellitus in the mother
A nurse is assessing a newborn's head after delivery. Which statement correctly differentiates caput succedaneum from cephalohematoma?
A. Caput succedaneum is swelling of the scalp’s soft tissues, while cephalohematoma is a blood collection beneath the periosteum of the cranial bone.
B. Cephalohematoma involves swelling of the scalp’s soft tissues, while caput succedaneum is a collection of blood beneath the periosteum.
C. Both caput succedaneum and cephalohematoma are caused by bleeding beneath the scalp.
D. Caput succedaneum protrudes from beneath the scalp and is a blood collection, while cephalohematoma is soft tissue swelling.
A nurse is teaching the parents of a newborn about circumcision care. Which of the following instructions should the nurse include? (Select all that apply.)
A. Keep the circumcision site clean and change diapers frequently.
B. Wash the area with warm water and avoid alcohol-containing wipes.
C. Remove the yellow crust on the penis daily to prevent infection.
D. Apply petroleum jelly (Vaseline) to the circumcision site at each diaper change.
E. Use loose-fitting diapers to prevent pressure on the area.
F. Observe for at least six wet diapers per day.
G. Report any redness, bleeding, or unusual drainage to the healthcare provider.
A nurse is assessing a newborn for signs of hip dysplasia. Which of the following manifestations should the nurse recognize as indicators of this condition? (Select all that apply.)
A. Limited abduction of the affected leg
B. Asymmetry of skin folds on the thigh
C. Shortening of the femur on the affected side
D. Lower knee position on the affected side
E. One buttock appearing higher than the other when prone
F. Increased abduction of the affected leg
A nurse is assessing a newborn for hypoglycemia. Which plasma glucose levels indicate hypoglycemia in term and preterm infants?
A. Less than 50 mg/dL in term infants and less than 40 mg/dL in preterm infants
B. Less than 40 mg/dL in term infants and less than 30 mg/dL in preterm infants
C. Less than 60 mg/dL in term infants and less than 50 mg/dL in preterm infants
D. Less than 30 mg/dL in term infants and less than 20 mg/dL in preterm infants
A nurse is assessing a newborn’s growth status. Which of the following correctly describes the classifications of birthweight for gestational age?
Additionally, what standardized method can estimate gestational age within 1 to 2 weeks based on external characteristics and neurological development?
A. Small for gestational age (SGA) is birthweight above the 90th percentile; average for gestational age (AGA) is birthweight between the 10th and 90th percentile; large for gestational age (LGA) is birthweight below the 10th percentile.
B. Small for gestational age (SGA) is birthweight below the 10th percentile; large for gestational age (LGA) is birthweight above the 90th percentile; average for gestational age (AGA) is birthweight between the 10th and 90th percentile.
C. Small for gestational age (SGA) is birthweight between the 10th and 90th percentile; average for gestational age (AGA) is birthweight below the 10th percentile; large for gestational age (LGA) is birthweight above the 90th percentile.
D. Small for gestational age (SGA) is birthweight below the 5th percentile; large for gestational age (LGA) is birthweight above the 85th percentile; average for gestational age (AGA) is birthweight between the 5th and 85th percentile.
